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 Table of Contents  
Year : 2016  |  Volume : 36  |  Issue : 2  |  Page : 51-56

Clinical profile of nail apparatus abnormalities in dermatology patients

Department of Dermatology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India

Date of Submission09-Aug-2016
Date of Acceptance09-Nov-2016
Date of Web Publication21-Mar-2017

Correspondence Address:
Rubina Jassi
R. No. 307, Department of Dermatology, Lady Hardinge Medical College, Shaheed Bhagat Singh Marg, Connaught Place, New Delhi 110001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-6530.202639

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Introduction Anatomically, nail is a hard protective covering over the terminal phalynx, and this helps to avoid any injury, as well as enhances the sensory perception over the pulp of digits. The nail apparatus consists of nail plate, nail folds, nail bed, and hyponychium. Various Diseases may affect the nail, eg infections, papulosquamous disorder, habitual dosrde and tumorers.
Patients and methods We included 250 patients aged more than 18 years presenting to our out patients department (OPD) primarily with nail complaints. A detailed history of the disease was taken, and all the 20 nails were examined. Relevant investigations (KOH scraping, pus culture sensitivity, or biopsy) were performed.
Results The age of the patients varied between 18 and 85 years, with a mean value of 35.37±15.16 years. Male to female ratio was 1:1.06. About 24 patients belonged to the geriatric age group. In all, 50 (20%) patients had their disease directly related to their profession. The most common presenting complain was discoloration followed by deformity. Finger nails were more commonly involved. The most common diagnosis was onychomycosis (55.6%), followed by traumatic nail (6.4%), chronic paronychia (4.4%), acute paronychia (3.6%), lichen planus (3.6%), onychocryptosis (3.6%), and eczematous nail changes (1.6%).
Conclusion Onychomycosis is the most common primary nail apparatus abnormality responsible for discoloration of nail presenting to dermatology OPD, followed by nail trauma, paronychia, lichen planus, and onychocryptosis.

Keywords: culture, KOH, melanoma, melanonychia, nail lichen planus, nail psoriasis, nail trauma, paronychia

How to cite this article:
Jassi R, Chander R, Mendiratta V. Clinical profile of nail apparatus abnormalities in dermatology patients. Egypt J Dermatol Venerol 2016;36:51-6

How to cite this URL:
Jassi R, Chander R, Mendiratta V. Clinical profile of nail apparatus abnormalities in dermatology patients. Egypt J Dermatol Venerol [serial online] 2016 [cited 2023 Jan 27];36:51-6. Available from: http://www.ejdv.eg.net/text.asp?2016/36/2/51/202639

  Introduction Top

Interestingly, nail serves as a vital source of dermatological, systemic, or nutritional status of the patient. Nail examination is essential in all individuals including patients of dermatological disorders.

Functional properties of nail are listed below [1]:

  1. Social, sexual communication, and esthetic appearance.

  2. Protecting the distal phalynx from any form of trauma.

  3. Contributes to the tactile discrimination and fine-motor capacities of the fingertips.

  4. Ability to scratch and groom as rudimentary natural weapon.

  5. Essential for full motor functions of feet by contributing to pedal biomechanics.

Some of the most common signs seen in the nail include [2] beau’s lines, onychomadesis, pitting, onychorrhexis, longitudinal groves, trachyonychia, leukonychia, koilonychias, melanonychia, erythronychia, onycholysis, splinter hemorrhage, paronychia, nail pigmentation, subungual hyperkeratosis, and onychoschizia. All these changes are associated either directly to a nail pathology or indirectly to a systemic pathology.

Various nail disorders can be grossly divided into traumatic, infective, papulosquamous, habitual, or benign/malignant tumors.

  Patients and method Top

Our study was a descriptive cross-sectional study in the department of dermatology in a tertiary care center from December 2013 to April 2015. All patients gave their formal consent. The protocol was approved the ethical committee of the Medical College.

All patients aged 18 years and more of either sex presenting primarily with nail complaints were included in the study after written and informed consent. A total of 250 patients were enrolled. Appropriate required history about the onset of disease, duration, occupation, activity, cutaneous diseases, systemic diseases, and medication was elicited. All 20 nails were examined, and the required investigations (nail KOH/culture/pus culture sensitivity/biopsy) were performed to establish the diagnosis.

Statistical analysis

SPSS, version 18, was used to analyze the data, and observations were analyzed as the percentage and mean.

  Results and observations Top

The age of the patients varied between 18 years and 85 years, with a mean value of 35.37±15.16 years. A maximum of 110 (44%) patients were present in the age group of 18–31 years. Geriatric age group (>60 years) had 24 (9.6%) patients ([Table 1] and [Table 2]).
Table 1 Table of age distribution and frequency of nail diseases

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Table 2 Table of age, duration, and number of nail involvement in patients of onychomycosis

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Out of the 250 patients, 129 (51.6%) were female and 121 (48.4%) were male. The male to female ratio was 1:1.06.

In all, 50 (20%) had their disease directly related to occupation (vendors, housemaids, security guards, etc.), 70 (28%) had their disease directly related to their daily activity (housewives), and 130 (52%) had their disease not related to their occupation or activity.

The duration of the disease ranged from 3 days to as long as 10 years. The mean duration of disease was 11.96±17.321 months (∼1 year).

The most common presenting complaint was only discoloration of the nail plate, which was found in 98 (39.2%) patients, followed by only deformity in 44 (17.6%) patients. Pain was the presenting feature in 20 (8%) patients. All other presenting complaints contributed less than 1.5% each.

Out of 250 patients, 73 (29.2%) were symptomatic, 54 (21.6%) patients had pain, 18 (7.2%) patients had itching, and 1 (0.4%) patient had complaints of easy breakability of nail.

Finger-nail involvement was seen in 182 (67.7%) patients, and toe nails were involved in 109 (40.5%) patients.

There was an overlap between finger-nail and toe-nail involvement in 22 (8.2%) patients.

In our study population, 19 clinical diagnoses were made. There were 139 (55.6%) patients with only onychomycosis as the diagnosis. Therefore, onychomycosis was the most common diagnosis ([Figure 1],[Figure 2],[Figure 3]). However in addition, traumatic nail changes were seen in 16 (6.4%) patients. Chronic paronychia was found in 11 (4.4%). Acute paronychia, lichen planus, and onychocryptosis each was seen in nine (3.6%) patients. Eczematous nail changes and idiopathic distal onycholysis were seen in four (1.6%) patients.
Figure 1 Toe-nail onychomycosis.

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Figure 2 Finger-nail onychomycosis.

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Figure 3 Proximal-nail onychomycosis.

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Each of the remaining diagnoses contributed to nail benign tumors (subungual wart, glomus tumor) in less than 1.5% of the study population ([Figure 4] and [Figure 5]). However, a combination of diseases was seen in various patients. A single case of acral toe-nail melanoma was also reported ([Figure 6]).
Figure 4 Subungual wart.

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Figure 5 Glomus tumor of nail bed.

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Figure 6 Melanoma of toe nail.

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Among the geriatric age group, onychomycosis was the most common disease. Nail lichen planus, nail psoriasis, and chronic paronychia were also present. Longitudinal melanonychia and eczematous nail changes were seen in one person each.

In patients diagnosed with onychomycosis, the mean age of patients was 36.56 years. Male to female ratio was 1.16:1. Average number of nails involved were three to four (3.73). Discoloration was the most common presenting complaint, followed by deformity. Cutaneous fungal infections were seen in 20.4% of patients. In all, 8.6% of patients had a history suggestive of immunosuppression. KOH mount was positive in 58% patients. Culture was positive in 22.8% patients, and Trichophyton spp. were most commonly isolated.

  Discussion Top

Nail disorders comprise ∼10% of all dermatologic conditions [3]. However, these data include all the patients presenting with nail diseases, as well as the patients in whom nail disease was diagnosed on examination.

The prevalence of primary nail diseases in our clinic was 0.94%. The only similar study conducted by Le Bidre et al. [4] included all the referred patients with nail complaints, and thus the data about prevalence in general OPD patients cannot be assessed.

In our study population, the age of the patients varied from 18 to 85 years, with a mean value of 35.37±15.16 years, and male to female ratio was 1:1.2. However, in a similar study conducted previously by Le Bidre et al. [4], the study population had a wider age range. The age of the patients ranged from 8 to 92 years. The mean age was 47.9 years, but male to female ratio of 1:1.5 was comparable.

The two studies imply that the nail diseases are more common in a higher age group.

There were 24 (9.6%) patients in the geriatric age group. Male to female ratio was 2.4:1. El-Domyati et al. [5], who studied nail changes in 200 geriatric patients, found an age range of 61–91 years (69±7.51 years) and a male to female ratio of 1.63:1 in comparison with 200 adults with an age range of 19–58 years (32.12±11.27) and a male to female ratio of 1.5:1. In another study conducted by Rao et al. [6], 100 geriatric patients were examined for nail changes and disease. The age group ranged from 60 to 101 years, and 65 were male and 35 were female. Male to female ratio was 1.8:1.

The duration of the complaints in our study ranged from 3 days to 10 years. The mean duration of presentation was 11.94 months (around 1 year). The duration varied according to the nature of the disease; however, there is hardly any data to compare with.

In all, 28% of patients had their disease related to their daily activity. It mainly included the housewives who had exposure to wet work and irritants, leading to onychomycosis, paronychias, or eczematous nail changes. Almost half of the study population had their disease related to their work (professional or personal) or habits. Thus, the use of appropriate preventive measures such as cotton-lined gloves for kitchen work is advised, therefore avoiding frequent and prolonged immersion and exposure to irritants, and appropriate footwear may help to decrease the risk of acquiring a nail disease.

In our study, the most common presenting complaint was discoloration (39.2%) followed by deformity (17.6%). Pain was the presenting feature in 20 (8%) patients. The other remaining presenting complaints (swelling, erythema, itching, shortening, pus/blood discharge, etc.) contributed less than 1.5% each. Multiple complaints were seen in 21.2% patients. Only 29.2% of patients were symptomatic. Most patients presented for personal apprehension or cosmetic concerns. However, no literature is available to compare the same.

In our study, a majority of the patients had involvement of finger nails. Finger-nail involvement was seen in 67.7% of patients, whereas toe nails were involved in 40.5% of patients. Involvement of both finger and toe nails was seen in 8.2% of the patients. In all, 52% of patients had involvement of the nail of the dominant hand. Le Bidre et al. [4] individually illustrated the nail involvement in all the diseases. In their study, the patients with toe-nail involvement outnumbered those with finger-nail involvement, and the reason might be attributed to the often use of closed pointed footwear.

As only one study of such kind is available, the comparison of the study by Le Bidre et al. [4] and our study is illustrated in [Table 3].
Table 3 Table of comparison of diagnosis between the study by Le Bidre et al. and the present study

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In our study, there were many patients with more than one diagnosis. A total of 24 patients had overlap of two diseases. The most common overlap was onychomycosis with chronic paronychia in 12 patients. One patient had overlap of onychomycosis with chronic paronychia with traumatic nail changes. Comparatively, very few overlaps were seen in the previous study, but onychomycosis with chronic paronychia was also the most common combination.

In our study, the most common diagnosis in geriatric patient was onychomycosis, contributing 66.6%. Other diagnoses such as chronic paronychia, lichen planus, eczematous nail changes, idiopathic distal onycholysis, lichen planus, and nail psoriasis were seen in one patient each (4.16%). One patient had overlap of onychomycosis with chronic paronychia and another had chronic paronychia with longitudinal melanonychia.

Rao et al. [6] studied nail changes in 100 elderly patients and found acquired disease in 33 (33%) patients. Onychomycosis was found in 16%, chronic paronychia in 9%, traumatic nail in 8%, psoriatic nail disease in 4%, periungual wart in 1%, and acute paronychia in 1% of patients.

In India, the infective pathologies have significant contribution. Infection diseases are more seen adult and geriatric age groups. In our study and the study by Rao et al. [6], the infective diseases were more often seen as compared with the French study.

In our study, 64.8% had onychomycosis. Thus, it was the most common disease in our study group. The mean age of the patients was 36.56 years (18–85 years), with 53.7% male and 46.3% female. Male to female ratio in our study was 1.16 : 1.

The prevalence of onychomycosis is known to increase with age [7]. Of late, various recent studies from India and worldwide have shown a lower mean age ranging from 29.40 to 41.35 years [8],[9],[10],[11]. Our study population also had a similar mean age group of the patients.

Onychomycosis had been reported to be more common in men. Various studies have reported male to female ratio of 3.1:1 [8], 3:1 [9], and 2.7:1 [12]. In the study by Le Bidre et al. [4], 31.6% patients had onychomycosis. The mean age was 55.5 years (range: 28–92). There were 58.1% women and 41.8% men. Male to female ratio was 1 : 1.38.

Kaur et al. [10] reported the occurrence of discoloration in 100% of patients and pain in 17% of patients, whereas Gupta et al. [8] reported occurrence of discoloration in 92% of patients. Yadav et al. [13] reported discoloration also in 97.4% of patients, followed by brittle nails and pain in 30.3% of patients in toe-nail onychomycosis.

In our study, we also found discoloration to be the most common complaint in around 50% of the patients, followed by deformity in 9.9% and combination of the two in 29.6% of patients. Pain was a symptom only in 8.6% of patients.

In all, 20.4% of patients had evidence of concomitant cutaneous fungal infection in our study. However, the study conducted by Kaur et al. [14], Sujatha et al. [15], and Yadav et al. [13] reported higher prevalence of associated cutaneous infections ranging from 31 to 45%. The average number of nails involved in our patient was 3.73. However, in a study by Jary et al., [16] the average number was 5.4. The number of nails involved were less than and equal to five nails in 57.6% of patients in a study by Gupta et al. [8], whereas Yadav et al. [13] reported the average number of nails infected to be 5.59.

Involvement of the dominant hand shows more risk of acquiring the infection, trauma, and exposure to wet work. In our study, a majority of the patients with finger-nail onychomycosis had involvement of the dominant hand.

KOH examination in suspected patients of onychomycosis could confirm the diagnosis in 48% in a large study involving 631 samples [17]. Other authors have reported variable sensitivities ranging from 50 to 60% [18],[19],[20]. However, in our patients, KOH positivity was around 58%, which was in agreement with previous studies.

The culture positivity was seen in only 22.8% of our patients, out of which a majority were Trichophyton spp. (59.6%), followed by nondermatophytic molds (20.1%) and Candida spp. (10.9%). Similarly, in the study by Le Bidre et al. [4], Trichophyton spp. were found in 60.4%, molds in 16.2%, and Candida spp. in 23.2% of patients.

The Achilles foot project (covering 80 396 patients from East Asia and Europe) found dermatophytes to be the most common causative organisms for onychomycosis, accounting for about 68% of all cases. This was followed by yeast (11%) and nondermatophyte molds (11% cases) [21].

  Conclusion Top

To conclude, onychomycosis was the most common primary nail apparatus disease in our OPD. Men and women had almost equal contribution in the study population. Almost half of the study patients had their disease related to their occupation or activity. Finger nails outnumbered toe-nail involvement. Primarily, nail apparatus abnormalities are sparsely studied. Therefore, further larger representative studies should be conducted to know about the disease profile of nail apparatus abnormalities in our country. Patients should be advised proper care of nails, increased awareness of nail diseases, and early approach to a nearby dermatologist.

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Conflicts of interest

There are no conflicts of interest.

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

  [Table 1], [Table 2], [Table 3]

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