Distorted, discoloured or otherwise unsightly fingernails and toenails are very common problems in people of all ages. Nail damage is frequently caused by injury or fungal infections. Skin conditions (such as psoriasis, eczema and alopecia areata) can also be evident in the nails. In addition, conditions affecting the internal body organs can sometimes be seen in the nails and might prompt further investigation, for example, bulbous nails (known as clubbing) can result from disorders affecting the lungs, heart or liver.
Below are a number of commonly experienced problems:
- Lifting of the nail plate (onycholysis) – often a result of repeated minor injury to the underside of the nail. It appears white rather than pink as air gets under the nail. This can also be caused by psoriasis, fungal nail infections (onychomycosis) or water immersion.
- Pitting – describes individual depressions around the size of a pinhead. This is commonly seen in psoriasis, other causes include eczema and alopecia areata.
- Ridging– either along (longitudinal) or across (transverse) the nail. Longitudinal ridging becomes more prominent with age or may be associated with conditions such as lichen planus and repetitive nail injury. Transverse depressions often appear after a significant illness (called Beau lines) or secondary to episodes of paronychia (see below) – which is often associated with nail biting. Fiddling with nails or cuticles can also produce irregular ridging.
- Thickening of nail (onychogryphosis) – frequently seen in toenails of the elderly often resulting from the long term use of ill-fitting footwear and neglect of the nails. It may also be secondary to medical conditions such as psoriasis or fungal infections.
- Yellow: commonly, this is due to fungal nail infection (oncychomycosis) but nails affected by psoriasis can also appear yellow. Smoking can also leave the nails yellow in colour. Very rarely, ‘yellow nail syndrome’ is seen, here yellowing of the nails is related to an underlying disorder affecting the lungs and lymphatics.
- Green: usually secondary to a bacterial nail infection (pseudomonas) or infection by a yeast called candida. Often pseudomonas infection can affect nails previously damaged by a common fungal infection or trauma.
- Brown: this can be caused by medications, chemicals from hair dyes, nail varnish, nicotine, trauma, chemotherapy and antibiotics. Rarely, melanomas may present as brown or black pigmentation on or under the nail – it is important to seek medical advice to rule out melanoma in the case of a single brown/black nail.
- White (leuconychia): this may run in families or can be caused by any medical condition that results in low levels of protein in the blood (i.e. hypoalbuminaemia – resulting from nephrotic syndrome or liver failure, for example).
- Inflammation of the nail fold (paronychia) – acute infection of the nail fold (cuticle) causes redness, swelling, tenderness and pain, sometimes with pus formation. It is often seen in nurses, hospitality workers and hairdressers, from over-zealous manicuring or when nails are immersed in water for long periods of time. Occasionally, this condition can be seen in infants who suck their thumbs. A long-term (i.e. chronic) variant is also seen. This requires meticulous hand hygiene.
Management at The Skin Hospital
There are many possible underlying causes of the problems noted above. Sometimes a diagnosis can be made without the need for any tests. Fungal nail infections are very common amongst the general population, therefore often a nail clipping will be taken for examination under a microscope and culture to assess if a fungus is present. A nail biopsy, where a piece of nail is surgically removed under local anaesthetic is very rarely required.
Treatment will depend on the underlying cause. Where the nail changes are related to a skin or medical condition, treatment of the underlying cause can usually improve the appearance of the nails. As the nails grow slowly, improvements take many months to become apparent.
Fungal nail infections are very common and can be very slow to respond to treatment:
- Topical therapy: antifungal paints and creams may be used to treat infection affecting small parts of the nails. The benefit of using these is that there are few side effects, however, success is not guaranteed and may require many months of treatment.
- Oral therapy: antifungal tablets (e.g. terbinafine, itraconazole, fluconazole) can be used alone or in combination with topical treatments and need to be continued for months to have a beneficial effect. These tablets can interact with other medications and may not be appropriate in patients with some medical conditions, so it is important to update the treating dermatologist with your relevant medical conditions. Blood tests may be needed prior to starting treatment and during therapy.
- Physical therapy: lasers have been shown to effectively treat fungal infection in some cases, though there is somewhat limited evidence available for this treatment. Laser treatments are available at our Darlinghurst and Westmead sites.
Dermatologist at The Skin Hospital with a special interest in nails:
- Dr Penny Alexander (Darlinghurst)
- Dr Keng Chen (Darlinghurst)
- Dr Monisha Gupta (Darlinghurst)
- Dr Esther Hong (Darlinghurst)
- Dr Joseph Krivanek (Darlinghurst and Westmead)
- Dr Hanna Kuchel (Darlinghurst)
- Dr Eddie Lobel (Darlinghurst)
- Dr Roland Nguyen (Darlinghurst)
- Dr Sarvjit Sohal (Darlinghurst and Westmead)
- Dr Nicholas Stewart (Darlinghurst and Westmead)
- Dr Kavita Enjeti (Westmead)
- A/Professor Pablo Fernandez-Penas (Westmead)
- Dr Claire Koh (Westmead)
- Dr Brian Wallace (Westmead)
- Dr Supriya Venugopal (Westmead)
Further information about nail disease can be obtained from the following trusted sites:
Website content updated by Dr Charlotte Thomas & Dr Nicholas Stewart, last updated 11 November 2015