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Nailing the Nail Diagnosis


As a part of her Maui Derm NP+PA Fall 2021 presentation, Phoebe Rich, MD, discusses how different diseases manifest in the nails, including multiple patient examples, and whether or not biopsy is needed for diagnosis.

Nailing the right diagnosis for patients with nail problems is key to avoiding unnecessary procedures, according to a speaker at the Maui Derm NP+PA Fall 2021 conference, being held both in Asheville, North Carolina, and virtually.

Phoebe Rich, MD, adjunct professor of dermatology and director of the Nail Disorder Clinic Oregon Health & Science University, Portland, Oregon, discussed nail disorders at the conference, sharing how to spot and treat each diagnosis, and giving insight on whether specific manifestations require biopsy.

One case Rich included in her presentation focused on second and third nail dystrophy of a woman in her mid 50s who had worsening nail changes for over 3 years. When tested, both mycology and punch biopsy were negative.

Rich explained that the patient was experiencing these issues because of carpal tunnel syndrome (CTS), explaining that a clue to this diagnosis was the damage location of the second and third finger of the patient.1

By determining the true cause, unnecessary medical and surgical treatments can be avoided, she said. To help determine the issue was a result of CTS, she recommended looking for atrophy in the patients hand and thenar muscle of the thumb.

Another patient example she presented had chronic, painful nail dystrophy, the cause of which she explained to be onychotillomania. Onychotillomania is an under diagnosed, but common, Rich said, nail problem which is often confused for lichen planus, psoriasis, onychomychosis, or tumors.

The symptoms of the disorder are categorized as:

  • Thin nails with a small nail bed
  • Cuticles that are often ragged, detached, and traumatized
  • Free edge of the nail being frayed chipped, or missing
  • Red areas of the nail plate are worn down and thin
  • Parallel scratch marks from surface filing

Onychotillomania is self-induced nail trauma and dermoscopy of the nail is used as a diagnostic tool, Rich explained. The dermoscopic features include a gray nail bed pigmentation, wavy lines in the nail plate, and multiple obliquely oriented nail bed hemorrhages.

It can be difficult to manage the disorder, Rich said, due to a patients self-denial of self-manipulation. She advised gentle, nonjudgmental support along with occlusive dressings, behavior modification, cyanoacrylate glue, hypnosis, or manicuring.

Rich quickly discussed multiple nail disorders, including:

Subungual Exostosis: An enlarging firm growth under the nail that can be x-ray diagnosed in most pediatric cases, however, there can be recurrence.

Quincke’s Pulse: When a patient’s nails are pulsating, refer them to a cardiologist as this is a sign of aortic regurgitation.

Onychomadesis: A proximal shedding of the nails, which is an arrest in nail growth, and often a sign of systemic disease. Regrowth can occur within 3 to 6 months without scarring.

Onychoheterotopia: A growth of the nail outside the normal nail unit. This can be a small outgrowth or a completely doubled nail and can be caused by either genetics or trauma, according to Rich. It can be associated with bone abnormalities and the matrix must be destroyed to prevent recurrence.

Retronycha: This is caused by the ingrowth of the nail plate into the nail fold and is usually due to trauma. The treatment is avulsion. It does show as multiple layers of nails.

Dariers: Dariers causes the nails to alternate red and white stripes in the nail and is caused by ATP2A2 gene mutation.

Clubbing of the Nail: This can lead to other diagnoses like lung disease and be diagnosed by looking at the Lovibond (an angle of more than 180 degrees) and Curths (an angle of less than 160 degrees).

Rich recommended a biopsy when the nail is presenting with brown vertical bands, fissures in the nail plate, irregular band color, and variability of pigmented bands, as it could be melanoma. She prefers removing the entire nail when doing a biopsy, taking the affected tissues, and attaching the nail back to the bed to help prevent infection.

Stay tuned for more coverage of Maui Derm NP+PA Fall 2021 Conference at www.dermatologytimes.com.


Rich reports no conflicts of interest in this presentation.


Rich P. Nailing the Diagnosis. Session presented at: Maui Derm NP+PA Fall 2021 conference Program; September 30, 2021; Accessed September 30, 202. Asheville, North Carolina.

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