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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 25  |  Issue : 2  |  Page : 119-123

Nail abnormalities associated with various dermatoses in a tertiary care center in North India: A cross-sectional study


Department of Dermatology, Christian Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission14-Feb-2021
Date of Acceptance03-Aug-2021
Date of Web Publication29-Mar-2022

Correspondence Address:
Dr. Abhinav David
House No. 71, New Staff Lines, Christian Medical College and Hospital, Ludhiana - 141 008, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdds.jdds_22_21

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  Abstract 


Background: Nail is an important structure both functionally and cosmetically. Nail examination is an integral part of a complete dermatological examination and can provide a clue in the diagnosis and severity of skin diseases. Purpose: The aim of the study is to study the pattern of nail changes in various dermatoses. Methods: The present study was a cross-sectional study conducted among 550 patients attending dermatology outpatient department in a tertiary care center in North India. A prestructured pro forma captured detailed demographic profile, clinical examination related to various dermatoses, and associated nail changes. KOH examination, fungal or bacterial culture, nail biopsy, and radiographic studies were done when indicated. The data analysis was done using the Statistical Package for Social Sciences (SPSS) version 21.0. Results: Majority of patients had onychomycosis (48%) followed by psoriasis (29%), paronychia (5%), vitiligo (4.7%), lichen planus (4%), and alopecia areata (2.3%). Twenty-nail dystrophy was noticed in three patients. The most common type of onychomycosis was distal lateral subungual onychomycosis (89%). Pits were seen in all psoriatic patients. Longitudinal ridges were the most frequent nail change in lichen planus (83%) and vitiligo (80%). Conclusion: Nails, in spite of being easily accessible for examination, are often overlooked. A variety of nail changes occur in various dermatological conditions and may be helpful in achieving a diagnosis.

Keywords: Dermatoses, nail abnormalities, nail disorders, pattern


How to cite this article:
David A, Alexander EE, Bhatia A. Nail abnormalities associated with various dermatoses in a tertiary care center in North India: A cross-sectional study. J Dermatol Dermatol Surg 2021;25:119-23

How to cite this URL:
David A, Alexander EE, Bhatia A. Nail abnormalities associated with various dermatoses in a tertiary care center in North India: A cross-sectional study. J Dermatol Dermatol Surg [serial online] 2021 [cited 2022 Jul 2];25:119-23. Available from: https://www.jddsjournal.org/text.asp?2021/25/2/119/341201




  Introduction Top


The human nail unit is a set of complex structures having both cosmetic and functional values.[1] The nail unit consists of six main components: (1) the generating portion: nail matrix, (2) the product portion: nail plate, (3) the ensheathing portion: “cuticle” or eponychium,[2],[3] (4) the supporting portion: nail bed mesenchyme (”dermis”) and phalangeal bone, also known as onychodermis, (5) the anchoring portion: specialized mesenchyme, which exists proximally between the phalanx and the matrix and distally between the phalanx and the lateral and distal grooves, and (6) the framing portion: nail folds (”nail walls”).[4],[5] The fingernails cover one-fifth of the dorsal surface of the digit, while on the great toes, they might cover up to 30% of the toe surface.[6]

Nail plate aids in manipulation of smaller objects with a more refined and precise dexterity by enhancing sensory discriminatory ability of fingertips, apart from shielding fingertips from trauma. Nails also serve the purpose of scratching and grooming and can also be a means of defense or attack. Nails are often modified or decorated as a cosmetic accessory, and at times are capable of representing an individual's social standing.[7]

Nail disorders comprise approximately 10% of all dermatological conditions.[8] In many dermatoses, certain nail changes serve as presenting features before other signs of underlying dermatoses occur.[9] Any portion of the nail unit may get affected by dermatological conditions and can lead to morphological changes in the nail unit.[9],[10] Nail changes are seen in various dermatoses such as psoriasis, lichen planus, onychomycosis, collagen vascular disorders, vesiculobullous disorders, and other papulosquamous disorders.[10]

Despite being an easily accessible structure for examination, nail evaluation is often overlooked in clinical practice. This study examined the pattern of nail changes in various dermatoses.


  Methods Top


This was a descriptive cross-sectional study conducted among 550 participants presenting with different dermatological conditions with nail changes. The study was approved by the Ethical committee vide letter no BFUHS/2K18p-TH/1514. All patients coming with nail changes in various dermatological conditions to the dermatology outpatient department during the period of the study and willing to give consent were included in the study, whereas patients with nail changes having underlying systemic diseases or drug-induced nail changes were excluded from the study.

The study utilized a prestructured pro forma to record detailed demographic profile, clinical examination related to various dermatoses, and associated nail changes. KOH examination, fungal or bacterial culture, nail biopsy, and radiographic studies were carried out when indicated. Photographs demonstrating nail changes were taken after obtaining consent from the patients.

The data analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0 IBM Corp., Armonk (N.Y., USA). Categorical variables were presented in number and percentage (%), whereas continuous variables were presented as mean ± standard deviation and median.


  Results Top


Most patients were male (male-to-female ratio of 1.33:1). The mean age was 43.0 years. The age group with the most cases (36.5%) was age 21–40. Sixty-six percent of patients were housewives. The mean duration of illness was 3.32 years, while nail involvement of 1–5 nails was most common. Onychomycosis (48%) was the most common dermatosis with nail changes followed by psoriasis [29%, [Table 1]]. The most common pattern of onychomycosis was distal lateral subungual onychomycosis [89%, [Figure 1]]. Discoloration (89.43%) was the most common nail change in patients with onychomycosis [Table 2]. KOH nail clipping examination was consistent with clinical diagnosis in 97% of patients. Pitting [Figure 2] was the most frequent nail change in psoriasis and was seen in all patients with psoriasis [Table 3]. In patients with paronychia, nail fold inflammation (74%) was the most common nail change seen [Table 4] and [Figure 3]. Median canaliform dystrophy (solenonychia) was seen in one patient with paronychia [Figure 4]. Longitudinal ridges (81%) were the most frequent nail finding in vitiligo [Table 5]. Most of the lichen planus patients (86%) had longitudinal ridges [Figure 5], and pterygium was seen in 4 patients [18.1%, [Table 6] and Figure 6]. In patients with alopecia areata, superficial pits in scotch plaid pattern [Figure 7] were seen in all patients. Ingrown toenail [Figure 8] inside the lateral nail folds was seen in 11 (2%) cases. Among them, great toenail was involved in 88%. In eczema, pitting and rippling of nail plate (33.3%) were the most common nail changes. Two patients with Darier disease had alternate white and red stripes, V-shaped notches at distal nail plate and dystrophy. Twenty-nail dystrophy [Figure 9] was seen in 2 patients (9%) of lichen planus and 01 patient (08.3%) of alopecia areata. Two patients had idiopathic Beau's lines and koilonychia.
Table 1: Nail changes in various dermatoses (n=550)

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Table 2: Nail changes in onychomycosis (n=265)

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Table 3: Nail changes in psoriasis (n=161)

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Table 4: Nail changes is paronychia (n=27)

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Table 5: Nail changes in vitiligo (n=26)

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Table 6: Nail changes in lichen planus (n=22)

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Figure 1: Distal lateral subungual onychomycosis of bilateral thumbnails

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Figure 2: Numerous coarse pits in a patient with psoriasis

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Figure 3: Proximal nail fold edema with nail plate discoloration and dystrophy in paronychia

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Figure 4: Medial canaliform dystrophy of heller

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Figure 5: Longitudinal ridges in lichen planus

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Figure 6: Dorsal pterygium in a patient with lichen planus

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Figure 7: Multiple superficial pits in scotch plaid pattern in alopecia areata

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Figure 8: Ingrown right great toenail

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Figure 9: Twenty-nail dystrophy in patients with concomitant alopecia areata and lichen planus

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  Discussion Top


Nail being a convenient structure for examination may often be overlooked. Various dermatoses affect the nails. Certain nail changes may serve as presenting features before other signs of an underlying disease become clinically evident. The correlation of these nail changes can be useful in diagnosis of various dermatological disorders.

The main limitation of our study was that diagnoses were made mostly on the basis of clinical features and to a lesser extent, on the basis of investigations such as nail biopsy and nail culture.


  Conclusion Top


The nail unit is a specialized keratinous structure which acts as a window in providing an insight into the underlying dermatological disorders. Nail examination is an integral part of a complete dermatological examination. This study was aimed to find the pattern of nail changes in various dermatological disorders and their respective associations. Many diseases share similar changes, but the correlation of the nail changes helps dermatologists toW reach a conclusive diagnosis.

For effective evaluation of the nail changes, awareness of various terminologies and classification of the nail disorders is essential. The knowledge of the normal and abnormal variants of the nail and their association with a wide range of diseases is beneficial not only for establishing a diagnosis but also for the specific management of the disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Snigdha J, Reddy BN, Prasad GK. A study on the pattern of nail changes and nail disorders in geriatric patients in a tertiary care hospital in a rural setting. Sch J App Med Sci 2016;4:4394-400.  Back to cited text no. 1
    
2.
de Berker D. Nail anatomy. Clin Dermatol 2013;31:509-15.  Back to cited text no. 2
    
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Haneke E. Anatomy of the nail unit and the nail biopsy. Semin Cutan Med Surg 2015;34:95-100.  Back to cited text no. 3
    
4.
Park JH, Lee DY, Ha SY, Jang KT, Kwon GY, Lee KH, et al. The concept of onychodermis (Specialized Nail Mesenchyme) is applicable in normal adult nail unit. Ann Dermatol 2017;29:234-6.  Back to cited text no. 4
    
5.
Perrin C. The nail dermis: From microanatomy to constitutive modelling. Histopathology 2015;66:864-72.  Back to cited text no. 5
    
6.
Haneke E. Surgical anatomy of the nail apparatus. Dermatol Clin 2006;24:291-6.  Back to cited text no. 6
    
7.
Jiaravuthisan MM, Sasseville D, Vender RB, Murphy F, Muhn CY. Psoriasis of the nail: Anatomy, pathology, clinical presentation, and a review of the literature on therapy. J Am Acad Dermatol 2007;57:1-27.  Back to cited text no. 7
    
8.
Karim AT, Sadeque SP, Khan MA, Hasan MS, Al-Azad MA, Siraj MS, et al. A Study of nail changes in various dermatoses. J Armed Force Med Coll Bangladesh 2015;11:38-44.  Back to cited text no. 8
    
9.
Singal A, Arora R. Nail as a window of systemic diseases. Indian Dermatol Online J 2015;6:67-74.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Puri N, Kaur T. A study of nail changes in various dermatoses in Punjab, India. Dermatol Online 2012;3:164-70.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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