Optimal diagnosis and management of common nail disorders

Key points

• Nail changes are not only cosmetic: they can point to an underlying systemic disease, infection or malignancy, so the nails should be examined at every medical visit.
• The diagnostic work-up should include a detailed history and examination of all 20 nail units; dermoscopy, imaging, histopathology and mycological tests may be needed.
• Longitudinal melanonychia is a hallmark sign of subungual melanoma and should always be investigated; findings concerning for malignancy need prompt referral to a dermatologist for evaluation and biopsy.
• Brittle nail syndrome affects up to 20% of the population, women twice as often as men; protection from water and chemicals and keeping nails short limit further damage.
• Treatment is targeted to the condition and may include topical or systemic medication, stopping an offending drug or surgery, together with education on nail care.

Overview

This review describes the clinical features, diagnostic approach and treatment of the most common nail disorders in practice: brittle nail syndrome, onychomycosis, paronychia, nail psoriasis, longitudinal melanonychia, Beau's lines, onychomadesis and retronychia. Their causes are infectious, inflammatory, neoplastic or traumatic, and overlapping findings can lead to misdiagnosis and treatment delays. This overview is based on the abstract and the main practice statements of the article.

Brittle nails

Patients should avoid water and chemical solvents by wearing cotton gloves under vinyl gloves for wet work, and heavy cotton gloves are recommended for dry work. People whose work involves repeated microtrauma should keep their nails short.

Onychomycosis and paronychia

Mycological confirmation of onychomycosis is necessary. Patients should be told that nails grow slowly and that improvement may continue after treatment ends, and laboratory values should be monitored in patients at increased risk. For acute paronychia, the digit should be soaked for 10-15 minutes several times a day; if infection persists, oral antibiotics with gram-positive coverage are started, with anaerobic coverage when oral flora is suspected. In refractory chronic paronychia, a trial of systemic antifungal treatment is recommended before surgery, and a neoplasm should be considered if symptoms persist.

Nail psoriasis and melanonychia

All patients with nail psoriasis should be counselled on nail care and on avoiding activities that aggravate the disease; ciclosporin is recommended only for short-term use. Most melanonychia is benign, but the presence of blood does not rule out nail unit melanoma, since melanomas may also bleed.

FAQ

When does a nail change need a biopsy?

Findings concerning for malignancy should be referred promptly to a dermatologist for evaluation and biopsy, and longitudinal melanonychia should always be investigated for subungual melanoma.

How can brittle nails be protected?

Wear cotton gloves under vinyl gloves for wet work and heavy cotton gloves for dry work, and keep the nails short if work involves repeated microtrauma.

What if chronic paronychia does not improve?

A trial of systemic antifungal treatment is recommended before surgery, and a neoplasm should be ruled out if symptoms persist despite treatment.

Source

Lee DK, Lipner SR. Optimal diagnosis and management of common nail disorders. Ann Med 2022;54(1):694-712. DOI: 10.1080/07853890.2022.2044511. Open access under CC BY 4.0. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.