1. SPIESS
MR

3. NAIL EXAM




Shape
Color
Flexbility
Growth rate: ~6 months from the cuticle to free
edge, 0.1mm/day

4. COLORS
Pink/Red: polycythemia, SLE, carbon monoxide
poisoning, angioma, malnutrition
White: anemia, cirrhosis, DM, chemo, renal failure
Yellow: Amyloidosis, yellow nail syndrome, median/ulnar nerve
injury, thermal injury, jaundice, DM
Green/Black: solvents, trauma, chronic Pseudomonas infection

5. SPOONED NAILS (KOILONYCHIA)
 Water drop test: imagine placing a drop of water on the nail. If
it would not fall of f it is spooned
 Causes:
 Iron deficiency
 DM
 Protein deficiency especially in sulfur-containing amino acids
(cysteine or methionine)

6. CENTRAL NAIL RIDGE
 Causes:
 Iron deficiency, folic acid deficiency, protein deficiency

7. CENTRAL NAIL CANAL/HELLER’S FIR
TREE DEFORMIT Y
 Cuticle usually normal
 Associations:
 Severe arterial disease
 Severe malnutrition
 Repetitive trauma

8. NAIL BEADING
 Endocrine Conditions: DM, thyroid disease, Addison’s

9. ROUGH
 Sandpaper/dull appearance
 Seen in:




Psoriasis
Chemical exposures
Lichen planus
Autoimmune diseases

10. NAIL THICKENING
 Slow growth produces thickness
 Causes:





Onychomycosis
Chronic eczema
PVD
Yellow nail syndrome
Psoriasis

11. ONYCHOLYSIS
 Associated with:
 Thyrotoxicosis, trauma, contact dermatitis, chemicals, porphyria
cutanea tarda

12. CLUBBING
 Angle between nail plate and fold greater than 180 degrees

13. CLUBBING
 Causes:
 Cardiac/Pulmonary (80%): R to L
shunts, endocarditis, pericarditis, lung CA, bronchiectasis, lung
abscess, empyema, pulmonary fibrosis. NOT COPD
 GI (5%): IBD, celiac, neoplasms (esophagus, liver, bowel)
 Hyperthyroidism (1%)

14. SPLINTER HEMORRHAGE
 A s s o c i a te d w i t h t r a u m a , I E , s c l e r o d e r m a , t r i c h i n o s i s , p i t y r i a s i s r u b r a
p i l a r i s , p s o r i a s i s , r e n a l f a i l ur e

15. TERRY’S NAILS
 Proximal paleness extending at least half -way up (often
eliminating the lunula) with a dark band distally. Seen in
states of stress (liver disease, CHF, DM2, advanced age)

16. LINDSAY’S NAILS/HALF AND HALF NAILS
 Pale proximal (edema and anemia) in kidney and liver disease. In renal
disease there is a brown transver se distal brown transver se band at the
junction of the er ythema and free edge

17. BEAU’S LINES
 Transverse depressed ridges caused by growth arrest. Seen in
severe infection, MI, hypotension/shock, hypocalcemia, postsurgical, malnutrition, some chemotherapies

18. MUEHRCKE’S LINES (LEUKONYCHIA
STRIATA)
 Due to edema to the nail plate. Usually 2 or more on one nail.
Seen in states of decreased protein synthesis or increased protein
loss, hypoalbunemia (<2.2), nephrotic syndrome and certain
chemotherapies. Don’t move and disappear when albumin
increases.

19. MEES’ LINES
 Transverse white lines (usually one per nail, no depressions) that
often will disappear if pressure is applied. Heavy metal poisoning
(strong association with arsenic and thallium), chemo, severe
illness

20. PITTING
 Non-specific sign for psoriasis, alopecia areata, eczema, lichen
planus

21. QUITTER’S NAIL
 Distal nicotine stains with demarcation and no staining
proximally seen when a patient quits smoking or changes to a
lower tar tobacco.

22. PERIUNGAL
Periungal telangiectasias: strong association with CVD:
SLE, dermatomyositis, scleroderma
Fibroma
Mucus cyst
Paronychia
Herpetic Whitlow

23. ACRAL LENTIGINOUS MELANOMA
 Seen on palms, soles, mouth but when occurs within the nail
a clue is that it involves the periungal region

24. HANDS
Pope’s Hand (Hand of Benediction)
What nerve is
af fected?
Claw Hand

25. HANDS
Bouchard’s and Heberden’s Nodes

26. HANDS
Boutonniere Deformity
Swan Neck Deformity
Ulnar Deviation

28. WHAT WOULD YOU EXPECT THIS PERSON
TO HAVE?

29. A)
B)
C)
D)
E)
Turner’s Syndrome
Holt-Oram Syndrome
Down’s Syndrome
Edwards Syndrome
Fragile X

30. C) Down’s Syndrome

32. 62yo F with history of proximal muscle weakness, weight loss
and dysphagia
What is causing this?

33. DERMATOMYOSITIS
Periungal
telangiectasias
Gottron’s
papules

34. REFERENCES
 The Stanford 25 – stanfordmedicine25.stanford.edu
 Published presentation on nail exam – Mark Williams, MD at
UVA