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That’s Some Weird Nail Polish You Got There!

2015; Elsevier BV; Volume: 66; Issue: 6 Linguagem: Inglês

10.1016/j.annemergmed.2015.10.017

1097-6760

Ryan Raam, Brittney DeClerck, Paul Jhun, Aaron Bright, Mel Herbert,

Traumatic Ocular and Foreign Body Injuries

SEE RELATED ARTICLE, P. 584. A 3-year-old boy presented to the emergency department (ED) with 2 days of spontaneous bilateral fingernail and toenail shedding. He was otherwise asymptomatic. He had no recent trauma or known toxic exposures. History was significant for a visit to the same ED 45 days before with a diffuse rash, oral ulcerations, and papules on his hands and feet. On physical examination, he was afebrile, smiling, playful, nontoxic, and well-appearing, without signs of dehydration. His fingernails and toenails were peeling away from the proximal nail bed. He had no associated rash. Diagnosis: onychomadesis.1Marshall D.M. Hansen J.D. Lazio M.P. Young boy with shedding nails.Ann Emerg Med. 2015; 66: 584Abstract Full Text Full Text PDF Scopus (1) Google Scholar If you’re like us, onychomadesis is a new word you can use to impress at your next cocktail party. Basically, your nail matrix temporarily stops growing, leading to nail shedding or dystrophy, manifested as brittle nails with white or yellow streaks on the sides of the nail beds or transverse nail splitting. Now, unless a patient comes in specifically with a complaint about his or her fingernails, chances are you won’t specifically notice the intricacies of the patient’s last manicure (you’d be forgiven if you mistook onychomadesis for the results of a medieval torture technique). However, there are some signs of systemic disease that manifest themselves in fingernails that may be helpful for diagnosis in the ED. Specifically, we’ll review abnormal color changes to fingernails that are particularly relevant. There isn’t a pot of gold at the end of this rainbow…just a whole lot of icky badness. As a caveat, this topic is very visually based and, like all physical examination findings, requires seeing lots of examples over and over to appreciate the nuances. We encourage you to consult a dermatology atlas or your friendly neighborhood search engine for examples. Also, the differential for some of these findings is extensive, but we’ll touch on the ones within each category that are most relevant and specific to you. Also known as melanonychia, blackened areas of the nail plate are common findings in patients. Up to 70% of blacks can have benign hyperpigmentation of their nails.2André J. Lateur N. Pigmented nail disorders.Dermatol Clin. 2006; 24: 329-340Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar, 3Mendiratta V. Jain A. Nail dyschromias.Indian J Dermatol Venereol Leprol. 2011; 77: 652-658Crossref PubMed Scopus (19) Google Scholar However, when it’s seen in an isolated digit (generally thumbs or great toes) in a longitudinal or linear pattern (striated), there should be concern for underlying subungual melanoma. Approximately 5% of whites and 15% to 20% of blacks and Asians studied with this finding ended up having biopsy-confirmed melanoma.4Tosti A. Piraccini B.M. de Farias D.C. Dealing with melanonychia.Semin Cutan Med Surg. 2009; 28: 49-54Crossref PubMed Scopus (107) Google Scholar An additional finding that may hint at melanoma is if the pigmented area is also found in the periungual skin (Hutchinson’s sign—and no, not herpes!) (Figure 1).5Yun S.J. Kim S.J. Images in clinical medicine. Hutchinson’s nail sign.N Engl J Med. 2011; 5: 364Google Scholar When you consider that the 5-year survival rate of patients with subungual melanoma is approximately 50%, it’s all that much more important to refer patients to the dermatologist for biopsy (RIP Bob Marley).6Paul E. Kleiner H. Bödeker R.H. Epidemiology and prognosis of subungual melanoma.Hautarzt. 1992; 43: 286-290PubMed Google Scholar Just don’t be referring every subungual hematoma from a smashed finger! Green nail syndrome, or chloronychia, is indicative of a local Pseudomonas aeruginosa infection of the nail plate. This is typically found in people such as dishwashers, barbers, and synchronized swimmers, who work in settings in which their fingernails are exposed to warm, moist environments. By some reports, it’s the most common bacterial infection of the nail but is little known because of its rare reporting.7Nenoff P. Paasch U. Handrick W. Infections of finger and toe nails due to fungi and bacteria.Hautarzt. 2014; 65: 337-348Crossref PubMed Scopus (22) Google Scholar It’s characterized by a greenish discoloration of the nail (Figure 2) in the setting of onycholysis (that’s separation of the nail from the nail bed, for us common folk).8Chiriac A. Brzezinski P. Foia L. et al.Chloronychia: green nail syndrome caused by Pseudomonas aeruginosa in elderly persons.Clin Interv Aging. 2015; 10: 265-267Crossref PubMed Scopus (39) Google Scholar Typically, there is some sort of inciting condition such as repeated microtrauma or psoriasis that causes onycholysis and allows a pseudomonal infection. There isn’t a consensus on the optimal treatment for this condition, but there are some reports of removal of the separated portion of the nail and use of 2% sodium hypochlorite,9Maes M. Richert B. de la Brassinne M. Green nail syndrome or chloronychia.Rev Med Liege. 2002; 57: 233-235PubMed Google Scholar topical polymyxin or bacitracin,10Greene S.L. Su W.P. Muller S.A. Pseudomonas aeruginosa infections of the skin.Am Fam Physician. 1984; 29: 193-200PubMed Google Scholar topical nadifloxacin,11Rallis E. Paparizos V. Flemetakis A. et al.Pseudomonas fingernail infection successfully treated with topical nadifloxacin in HIV-positive patients: report of two cases.AIDS. 2010; 24: 1087-1088Crossref PubMed Scopus (9) Google Scholar or oral ciprofloxacin.8Chiriac A. Brzezinski P. Foia L. et al.Chloronychia: green nail syndrome caused by Pseudomonas aeruginosa in elderly persons.Clin Interv Aging. 2015; 10: 265-267Crossref PubMed Scopus (39) Google Scholar It’s important to treat this condition to prevent spread of the infection to other systemic sites. The last thing you want is for your patients to spread this from their fingernail to the cavernous sinus while picking their nose. Actually, this is a great way to scare your children from ever picking their nose again! White nails, or leukonychia, are a physical examination finding often encountered in a wide variety of patients. The differential for this is quite large, including anemia, benign leukonychia punctata (those little white spots on your nails when you were a kid that you were always told were from calcium deficiency…it’s not; it’s likely from just minor trauma), and hypoalbuminemia. There are 2 particular presentations of white nails that can be helpful to know as an emergency physician: half-and-half nails (Lindsay’s nails) and Terry’s nails. Half-and-half nails are exactly how it sounds: white nail bed on the proximal half and pinkish-red on the distal half (well, more like distal 20% to 60%) (Figure 3). Approximately one fifth of patients with chronic renal failure will have this finding, but it is specific for renal disease, particularly indicating some degree of uremia.12Udayakumar P. Balasubramian S. Ramalingam K.S. et al.Cutaneous manifestations in patients with chronic renal failure on hemodialysis.Indian J Dermatol Venereol Leprol. 2006; 72: 119-125Crossref PubMed Scopus (109) Google Scholar, 13Dyachenko P. Monselise A. Shustak A. et al.Nail disorders in patients with chronic renal failure and undergoing haemodialysis treatment: a case-control study.J Eur Acad Dermatol Venereol. 2007; 21: 340-344Crossref PubMed Scopus (38) Google Scholar Unlike uremic frost (described in one of our earlier Annals commentaries14Aguilera P. Jhun P. Bright A. et al.Why does your dandruff smell like urine?.Ann Emerg Med. 2015; 65: 342-344Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar), this nail finding does not correlate with the degree of uremia.15Leyden J.J. Wood M.G. The “half-and-half” nail: a uremic onychopathy.Arch Dermatol. 1972; 105: 591-592Crossref PubMed Scopus (36) Google Scholar Generally, no intervention is needed, but these nail findings will usually improve with treatment of the underlying kidney disease.16Yang C.S. Robinson-Bostom L. Lindsay’s nails in chronic kidney disease.N Engl J Med. 2015; 372: 1748Crossref PubMed Scopus (4) Google Scholar, 17Gagnon A.L. Desai T. Dermatological diseases in patients with chronic kidney disease.J Nephropathol. 2013; 2: 104-109Crossref Google Scholar Terry’s nails are similar to half-and-half nails, but these aren’t just a fashionable French manicure. They are more specific to cirrhosis and are characterized by a white appearance of the nail bed, with a small brown 1- to 2-mm rim on the distal edge of the nail.18Wolff K. Johnson R.A. Fitzpatrick T.B. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, Seventh Edition. McGraw-Hill Medical, New York, NY2013Google Scholar Up to 80% of patients with cirrhosis or severe liver disease will demonstrate this nail finding.19Fawcett R.S. Linford S. Nail abnormalities: clues to systemic disease.Am Fam Physician. 2004; 69: 1417-1424PubMed Google Scholar Although these white nail findings describe more chronic conditions, it may be something to look for next time a 70-year-old patient who has “no medical problems” rolls into the ED, or in resource-limited areas in developing countries in which access to laboratory tests is not as readily available. Splinter hemorrhages are surprisingly not an uncommon nail finding in patients. They are defined as 1- to 3-mm-long linear lines that can be red and then transition to brown or black (Figure 4). The exact underlying nail pathology is not completely understood but is thought to relate to capillary bed destruction or emboli to the nail bed vasculature.20Zaiac M.N. Walker A. Nail abnormalities associated with systemic pathologies.Clin Dermatol. 2013; 31: 627-649Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar Traditionally, it’s taught that this examination finding is closely related to bacterial endocarditis. But as it turns out, like most dogma, things aren’t always what they seem. Splinter hemorrhages are neither sensitive nor specific for endocarditis. They occur in only 15% of patients with endocarditis and may be found in up to 20% of patients without it!21Daniel 3rd, C.R. Osment L.S. Nail pigmentation abnormalities. Their importance and proper examination.Cutis. 1982; 30: 348-360PubMed Google Scholar To make matters worse, splinter hemorrhages are seen in various other conditions, most common of which is just good old-fashioned local trauma to the nail. It’s definitely no North Star, but in the appropriate clinical context, it may point you in the right direction. Here are the “OPQRSTUs” of splinter hemorrhages: OCPs, Psoriasis, “Qancer” (yeah, yeah, we see your eyes rolling), Rheumatologic diseases, Subacute bacterial endocarditis, Trauma, Ulcer (peptic). Yellow nail syndrome is a fairly rare condition but is often mistaken for other systemic pathology. The nails are a distinctive yellow color (Figure 5), which can also be seen in chronic smokers and patients with jaundice. However, the syndrome is a specific disease characterized by yellow nails, lymphedema, and respiratory symptoms (eg, bronchiectasis, recurrent pleural effusions). Sounds a lot like congestive heart failure, right? But this won’t respond to nitroglycerin and diuretics because it’s primarily a functional problem of the lymphatic system. Although there is no standard treatment, one review found that more than 80% of pleural effusions in yellow nail syndrome were effectively treated with pleurodesis.22Valdés L. Huggins J.T. Gude F. et al.Characteristics of patients with yellow nail syndrome and pleural effusion.Respirology. 2014; 19: 985-992Crossref PubMed Scopus (38) Google Scholar Blue nails are also pretty rare, but when they do occur, it’s typically limited to the lunulae (the white crescent-shaped part of the proximal nail bed). Outside of acrocyanosis, which will usually involve more than just the fingernail, you may see this in a patient with colloidal silver ingestion (argyria).23Kalouche H. Watson A. Routley D. Blue lunulae: argyria and hypercopperecaemia.Australas J Dermatol. 2007; 48: 182-184Crossref PubMed Scopus (18) Google Scholar And, although you might think that this is stuff of the past, like medieval snake oil treatments, a simple Google search will show you that colloidal silver is still sold as part of homeopathic treatments. Yikes! On a side note, for the toxicology geek in all of us, blue lunulae may also be seen in Wilson’s disease, which, if you remember, is a toxic accumulation of copper in your tissues. With the increasing amount of culture-specific alternative medicine use, these nail findings may betray the patient who “isn’t taking any medications” (ever been burned on that one?). So to recap: black gets the whack, green needs antibiotic cream (well, technically topical or oral antibiotics), white’s not filtering right, red in the nail bed doesn’t always mean a drug head, yellow is hard to breathe for a fellow, and blue’s a clue to stop your holistic voodoo. As the case suggested, our patient had a previous hand-foot-mouth disease from coxsackievirus, of which onychomadesis is a “known” sequela (honestly, that was news to us too). Nail bed changes typically start 1 to 3 months after the infection and generally resolve spontaneously, as was the case for our patient. Young Boy With Shedding NailsAnnals of Emergency MedicineVol. 66Issue 6PreviewA 3-year-old boy presented to the emergency department (ED) with 2 days of spontaneous bilateral fingernail and toenail shedding. He was otherwise asymptomatic. He had no recent trauma or known toxic exposures. History was significant for a visit to the same ED 45 days before with a diffuse rash, oral ulcerations, and papules on his hands and feet. On physical examination, he was afebrile, smiling, playful, nontoxic, and well-appearing, without signs of dehydration. His fingernails and toenails were peeling away from the proximal nail bed (Figures 1 and 2). Full-Text PDF