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Nail Pitting. Causes of Pitting. Types of Pitting. Important Facts Nail pitting and onycholysis.

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Indian J Dermatol Venereol Leprol ; Important Facts About Nail Pitting. Guidelines of care for nail disorders. J Am Acad Dermatol ; Zaias N. The nail in health and disease, 2 nd ed Norwalk: Appleton and lange; Tosti A, Piraccani B, Dermatologic diseases. In: Scher RK, editor. Nails Diagnosis, Therapy and Surgery, 3 rd edition. Phiadelphia: Saunders; Physical signs. Diseases of the nail and their management.

Oxford: Blackwell Scientific Publications; Isotretinoin - induced elkonyxis. Br J Dermatol ; Nail Changes associated with diabetes mellitus. The nail in dermatologic diseases. Diseases of nail and their management, 2 nd edition.

Nail Deformities and Dystrophies - Dermatologic Disorders - Merck Manuals Professional Edition

Daniel CR 3rd. Onycholysis: an overview. Seminars in Dermatology ; Fingernail growth in idiopathic and psoriatic onycholysis.

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  7. Baran R, Juhlin L. Photo-onycholysis due to tetracycline. Blisters are rarely present or minimal at birth, and they may occur at approximately the age of 18 months; some individuals manifest the disease in adolescence or early adulthood. The nail dystrophy can be permanent, with anonychia, progressive hyperkeratosis with onychogryphosis, nail thickening, and parrot beak nail deformity in adult life [ 19 ]. In congenital malalignment of the great toenail, the matrix is laterally deviated and not parallel to the corresponding axis of the distal phalanx, which is why it produces a short dystrophic nail Fig.

    This deviation frequently causes periungual inflammation, onychogryphosis, and alterations to the nail plate, with ridging due to trauma to the position of the toenail. Spontaneous improvement is possible with a good nail bed attachment and persistence only of a malaligned appearance. When there is no improvement by the age of 2 years, the nail stays thick, triangular, medially bent, discolored, and oystershell-like with severe onycholysis.

    A surgical approach is recommended in severe cases [ 21 ]. Congenital hypertrophy of the lateral nail folds is present at birth or shortly thereafter due to asynchronism between the growth of the nail plate and that of the soft tissues [ 4 ]. Possible complications due to hypertrophy of the folds are painful paronychia, koilonychias, and malalignment of the same digit. Spontaneous improvement may occur over time within the 1st year of life.

    If no improvement is evident after this period, surgery is a possible option to consider [ 21 ]. Vertical implantation of the nail of the 5th toe is an uncommon disorder that consists of a lateral implantation of the 5th toe matrix. The nail virtually grows in a vertical direction, and bends backwards with great discomfort especially when socks are pulled on. In addition, it creates an aesthetic inconvenience [ 7 ]. Keeping the nail extremely short usually suffices to solve the inconvenience of the condition, but a possible option is complete nail ablation with phenolization [ 4 ]. Curved nail of the 4th toe is mostly described in young Japanese patients, where the 4th digit, usually bilaterally, is curved without any bone or soft tissue alteration.

    It is a congenital condition inherited as an autosomal recessive trait [ 7 ]. No explanation is described for this condition. It has no clinical significance and is not associated with any syndrome. Although it is congenital, usually it is noted after birth because of the deformity of hypoplasia of the distal phalanx [ 4 ]. Anonychia and micronychia can be isolated or part of several complex syndromes — such as Iso-Kikuchi syndrome, ectodermal dysplasia, and nail-patella syndrome — or in utero exposure to toxins.


    Nail Deformities and Dystrophies

    The term anonychia describes either partial or complete absence of the nail Fig. It can be congenital and associated with other deformities describing an autosomal or recessive inheritance. However, it can also be acquired after a great event inducing the complete destruction of the affected area, such as blisters in EB [ 19 ] or inflammation in nail lichen planus. The term micronychia identifies a congenital malformation with hypoplasia of the nail plate. It can be secondary to exposure to teratogenic drugs in early pregnancy or part of a syndrome [ 7 ].

    An event within a digit will limit the feature to that digit. A generalized event, such as systemic illness, may create a groove in multiple digits. When the underlying event is great, a detachment of the nail plate from the proximal nail fold results in a full-thickness transverse interruption of the nail plate, followed by shedding of the nail, known as onychomadesis. Drug eruptions as well as systemic infections are considered trigger factors for the onset of onychomadesis [ 22 ].

    Frequently, infants suck one finger, usually a thumb, even during the visit to the doctor. Thumb-sucking is a common childhood habit that may increase microbial exposure. Thirty-one percent of children are frequent thumb-suckers at more than 1 year of age [ 23 ]. The prolonged exposure of the skin of the digit to saliva induces maceration and irritation, with contact dermatitis of the periungual tissue causing cuticle damage and paronychia.

    Another possibility is the habit of pushing back the cuticle, which induces surface abnormalities washboard nails. One or more bands of longitudinal melanonychia can appear due to melanocytic activation after these types of trauma to the nail matrix. Periungual warts and bacterial paronychia are common infective complications that require a specific local therapy.

    One of the most studied infections is hand, foot, and mouth disease, where the relationship with onychomadesis is well described [ 24 ]. Onychomadesis of several or all nails occurs 1—2 months after the acute infection Fig.


    This is a common pediatric viral infection with vesicular eruptions that involve the palms, soles, and oral cavity. Nail shedding starts to present without pain or inflammation until complete separation of the nail plate in transversal ridging of several or all fingernails and toenails.

    This condition is reversible and self-limited, but the exact mechanism by which the illness induces this damage to the matrix is unknown. No specific treatment is required, only to reassure the family. Onychomadesis in the fingernails due to hand, foot, and mouth disease.

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    In chevron or herringbone nails, the nail plate surface shows oblique and longitudinal diagonal ridges converging towards the center of the nail plate at the distal part, describing a central spine with the appearance of a V-shape or a chevron. It appears between the age of 5 and 7 years and disappears in early adulthood [ 25 ]. It affects several or all fingernails, with an undetermined etiology [ 4 ]. Pachyonychia congenita is an uncommon genodermatosis characterized by defective keratinization. Clinical features include hypertrophic nail dystrophy, painful palmoplantar blisters, cysts, follicular hyperkeratosis, and oral leukokeratosis.

    Its inheritance is autosomal dominant, but sporadic and autosomal recessive cases are reported [ 27 ]. There are two types of pachyonychia congenita: type 1, also known as Jadassohn-Lewandowsky syndrome, and type 2, also known as Jackson-Lawler syndrome; they are linked to mutations in genes encoding five differentiation-specific keratins: 6A, 6B, 6C, 16, and Early development of nail thickening with an increased curvature due to nail bed hyperkeratosis, associated with palmoplantar keratoderma, is the clinical manifestation.

    By the age of 10 years, pain can be present as a symptom, which greatly impairs quality of life [ 28 ]. Cuticle loss makes it more difficult for the proximal nail fold to play its protective role and means that the first seal is broken. Acute paronychia is a painful bacterial or viral infection resulting from a break in the skin, a prick of a thorn, or a splinter Fig. After the infection, an inflammatory response ensues in the digit, with resultant swelling, erythema, tenderness, and secondary pus formation [ 4 ].

    As the nail matrix in children is particularly fragile, even a mild acute paronychia may induce permanent nail dystrophy. Chronic manipulation, inflammation, or infection can result in chronic absence of the cuticle, i. Possible therapies include compression primarily and local medication with antibiotic cream secondarily.

    In case of a strong reaction, possible drainage is advised and specific systemic antibiotic or antiviral therapy has to be started.

    Diseases and Disorders of the Nails

    Blistering distal dactylitis is a rare, localized infection by gram-positive bacteria that most commonly affects children. It is characterized by development of an acral oval fluid-filled bulla, 10—30 mm in diameter, usually on one finger pad [ 31 ]. The age group affected is 2—16 years old. The bulla can evolve into erosions over the course of several days. A differential diagnosis includes herpetic whitlow, EB, bullous impetigo, and friction blisters.

    Culture is necessary for a differential diagnosis and to identify the organism for the choice of treatment.