The nail is a layer covering the outer part of the fingertips and toe tips in humans and in many vertebrate animals. All healthy individuals should have this structure, called the nail, on each finger and toe. Nails are made of a hard protein called keratin.
Our nails, which are an appendage of the epidermis located on the outer surface of the tips of our fingers and toes, make it easier to hold objects and provide support to the fingertips, have an almost rectangular shape and are convex. Structurally they are hard and semi-transparent. They consist of 100–150 layers of corneocytes, 0.5 to 0.7 mm thick. The nail grows over the nail bed. The light-coloured, half-moon-shaped area on the nail is called the "lunula". In a healthy person, nails grow by about 0.9 mm a week.
Fingernails grow faster than toenails. The rate of nail growth can vary from person to person according to seasonal and hereditary factors. Nails can also sometimes become dry and be affected by certain diseases.
The part of the nail extending into the tissue to which it is attached is called the root, the part on the finger is called the body, and the part extending beyond the finger is called the nail tip. The natural colour of our nails is pink and its shades. However, this can vary depending on carbon dioxide intake, heavy use of detergents and smoking.
Causes of Nail Breakage and Wear
The most important cause of nails breaking and wearing easily is environmental factors. Examples of these factors include nails being constantly wet, exposure to chemicals such as acetone, frequent manicures, and cutting the nails too short or leaving them too long. In addition, some diseases can cause breakage or deformity of the nails. Thyroid diseases, vitamin deficiencies, anaemia, and eczema or psoriasis of the skin around the nails can also lead to nail damage.
In nail diseases, signs appear on the nail plate, the skin tissue around the nail, the nail bed and the lunula. We can classify nail diseases according to their location and signs.
* Clubbing: a condition in which there is an increase in the curvature of the nail and growth of the tissue at the tip of the nail.
* Spoon nail: a hollow-like structure forms in the body of the nail. It is a condition that results from thinning of the nail.
* Pincer nail: the nail curves inwards and over time becomes rolled. The nail digs into the sides. This nail structure can be caused by psoriasis, wearing tight shoes and bone tumours.
* Nail Fungus
Nail fungus appears as thickening of the nail plate and yellow-brown discolouration. It can occur on both fingernails and toenails. Fungi settle and live in keratin, the outer layer of the skin. However, they can also enter hard keratin such as the nail, resulting in a fungal infection of the nail. Affected nails take on a yellowish-white colour, thicken and crumble. Less often, white spots and lines may also be seen on the nail. Fungi most like to settle in the 1st and 5th toenails. In fingernails, if more than one nail is affected, they are usually the nails of the same hand. There may also be redness, swelling and pain in the skin around the nail. Fungal infections of the nail do not heal on their own and must be treated. If not treated, they can cause soft tissue infections (such as cellulitis and erysipelas). The aim of treatment is to get rid of the nail fungus. The nails will then return to their normal appearance. However, if the nail was already abnormal before it was infected with fungus, it is quite difficult for it to clear completely and return to its original state.
Treatment of nail fungus is long-term and requires patience. It should be treated with special lacquers applied to the nail and oral antifungal drugs. Oral drugs should be used for 3–4 months. In recent years we have been using laser methods in the treatment of nail fungus. Laser treatment is carried out in a total of 4 sessions, 1 session a week.
* Ingrown Toenail
The most important cause of an ingrown toenail is incorrect nail cutting. The nail should not be cut too deep. When cutting, the nail should be cut straight, not curved. What matters in resolving the problem of ingrown nails is ensuring that the nail is cut correctly. Ingrown nails result from wearing narrow, pointed shoes, cutting the nails too short and incorrect pedicures. The side edges of the nail curl and enter the skin, and redness develops around the ingrown nail. A persistent ingrown nail can subsequently lead to infection. The pain caused by an ingrown nail causes discomfort when walking. If there is an active infection before treatment of the ingrown nail, the infection should be treated first. If there is a mild ingrown nail, relief is provided by using wire or gauze to separate the nail from the part where it is digging in.
Ridges and Grooves on the Nail Surface
These can run longitudinally or transversely on the nail plate. They result from pathologies of the nail matrix and nail fold.
Anonychia
This is the partial or complete absence of the nail. The nail plate is very thin or completely absent. It may be congenital, or damage to the nail matrix can cause this clinical picture. When anonychia is congenital, it may be accompanied by developmental delay, abnormal facial appearance and abnormal tooth development. The presence of anonychia of the toenails can be part of nail–patella syndrome.
Acute Paronychia
If the clinical duration of paronychia is less than 6 weeks, it is called "acute paronychia". It usually affects one nail. Involvement of multiple nails is seen in chronic paronychia.
Acute paronychia can develop due to allergic contact eczema, contact irritants, fixed drug reactions, dyshidrotic dermatitis, high-dose methotrexate, cancer drugs, retinoids, antiretroviral drugs and monoclonal antibodies. Acute paronychia can also develop with herpes infection. Here we will mostly discuss paronychia of bacterial origin. Staphylococcus aureus, streptococci and pseudomonas are the most common bacterial causes. Prevotella bivia is rarely seen in paronychia but is important because it can cause osteomyelitis. Among fungi, Candida albicans is the most common cause of acute paronychia.
Trauma to the skin around the nail and overly harsh manicures disrupt the integrity of the skin, allowing bacteria to settle in this area of the nail unit. Sudden-onset swelling, tension and pain develop around the nail, and even purulent discharge may develop.
Chronic Paronychia
When paronychia lasts for more than 6 weeks, it is called "chronic paronychia". Compared with the acute form, the most common cause is eczema of the hands and fingers. If paronychia develops without being related to psoriasis, eczema or other systemic diseases and drugs, it is called simple chronic paronychia.
In chronic paronychia there is physical or functional damage to the cuticle. The cuticle develops from the proximal nail fold and adheres tightly to the nail plate there. This natural defence system protects the tissues around the nail, and especially the matrix, against external factors and microorganisms. The cuticle is damaged by manicures, irritants and excessive picking by the person. Maceration and foreign bodies in the skin of the proximal nail fold and the cuticle are the main causes of chronic infection. In children, finger sucking may be the main cause. Poor skin hygiene plays a role. Apart from trauma, contact with chemical substances may also be observed.
Candidal Onychomycosis
It is rare. Infection of the nails and nail folds with Candida species is seen especially in people whose hands are constantly in contact with water for occupational reasons (laundry workers, dishwashers and cooks). The infection usually starts from the lateral nail fold. The surrounding tissue may be erythematous, oedematous and tender. The nails are dull and of the non-crumbling type. Longitudinal white lines are often seen on the nail plate. The nail may turn brown or other colours depending on the presence of secondary infection. The most characteristic finding of candidal onychomycosis is the absence of subungual hyperkeratosis, showing that the nail bed is not involved. It is seen more on the fingernails, especially the middle finger. It is known to be relatively rare on the toenails.
Tinea Unguium
Fungal diseases of the nails are defined as "onychomycosis". The nail bed, matrix and plate may be infected individually or together. The term onychomycosis covers not only nail mycoses caused by dermatophytes but also those caused by yeasts and moulds. Onychomycosis caused by dermatophytes is called tinea unguium. It accounts for 30% of fungal skin diseases and 50% of nail diseases. The disease is seen consistently throughout the world and its incidence is gradually increasing. About 30% of patients with a cutaneous fungal infection also have onychomycosis. In one third of patients with tinea pedis, onychomycosis also accompanies the picture. 15–20% of people aged 40–60 develop this disease.
The functions of the nail unit include numerous roles such as protecting the distal phalanx, supporting touch, increasing tactile sensitivity, gripping objects and taking part in activities such as pressing buttons. Besides all this, nails are also very important cosmetically. Onychomycosis can be severe enough to prevent the nail from performing these functions. In addition, the appearance of a nail with onychomycosis and fear of spreading the disease to others lead to psychosocial problems for the patient. The fact that nails with onychomycosis form a reservoir for dermatophytoses is also an important problem.
It is seen especially at older ages. The rapid growth of nails in children may be a factor protecting children from onychomycosis. Although nail infections due to dermatophytes are more common in men, their frequency is also gradually increasing in women; the reason for this may be the narrow-toed shoes worn.
Some people are more susceptible to fungal nail infection. These people include:
- People with diabetes
- People with circulation problems
- People with immunodeficiency (e.g. AIDS/HIV infection)
- People aged 65 and over
- People with a fungal infection of the skin of the feet
- People whose feet sweat a lot or stay constantly damp
- People who put a lot of strain on their feet, such as athletes, runners and dancers.
The fungal agents that cause fungal disease of the nails are Trichophyton rubrum (the most common cause), E. floccosum and Microsporum fungi. Apart from these, mould-group fungi such as Candida also frequently cause nail disease.
Fungal nail disease is contagious. The fungi that cause the infection are found in warm, damp, shared places:
- Changing rooms
- Inside shoes
- Swimming pools
- Shared showers and bathrooms
- Gardens
- Unsterilised manicure or pedicure instruments
Clinical Features
Fungal nail diseases are classified according to the anatomical area of the nail in which the fungus settles. This clinical typing of onychomycosis is only possible in the early stages of the infection. In all types, in the advanced stages of the disease the whole nail is involved and takes on a completely dystrophic appearance.
Darier's Disease
Darier's disease is one of the common genodermatoses. Although it usually shows autosomal dominant inheritance, many cases with new mutations have been described. It occurs as a result of disruption of epidermal homeostasis in the skin due to damage to the ATP2A2 gene on chromosome 12q23–24.1, which encodes a calcium pump.
Clinically, the disease generally follows a more severe course in men than in women.
Clinically, typical lesions are seen mostly on the neck, middle of the chest, in the skin folds of the armpits and groin, on the scalp and on the arms and legs. It often prefers seborrhoeic areas, i.e. anatomical sites of the body rich in sebum (oil) secretion. Clinically, on the limbs there are thin, keratotic, raised papules a few millimetres in diameter, covered with a tightly adherent grey-brown crust.
Over time the lesions merge to create a thicker and dirty-looking appearance. Lesions in the skin folds look like sores, are malodorous, and secondary infections frequently develop. Although not very common, nodular lesions and vesicles may form.
Pits with small keratotic plugs may form on the palms and soles.
On the backs and sides of the hands, thin, flat-topped papules classically known as "acrokeratosis verruciformis" are seen.
On the nails, subungual keratosis, red and white streaks and V-shaped notches towards the tip of the nail may form.
Small raised papules forming white groups may be observed inside the mouth.
Because of a positive Koebner phenomenon (development or flare-up of the disease in areas exposed to trauma and external factors), sunlight, trauma and chemical irritants can make the disease worse.
The disease follows a chronic course with flare-ups and remissions, but severe complications are rare. Flare-ups may be seen in the summer months and after heat, humidity and mechanical trauma. In addition, steroids, lithium, phenol and ethyl chloride sprays can also cause flare-ups. Recurrent localised or widespread viral, fungal and bacterial infections of the skin are common complications.
Treatment
In the treatment of Darier's disease, sunscreens, moisturisers, cortisone creams, topical retinoids and tacrolimus can be used in mild forms, and synthetic vitamin A derivatives such as acitretin can be used systemically for widespread lesions. Topical retinoids have been found to be effective for localised disease. However, because of the irritating effects of topical retinoids, tazarotene and adapalene, developed as topical retinoids with fewer side effects, have recently been preferred.
Other treatment methods are salicylic acid, lactic acid, topical steroids, tazarotene, 5-fluorouracil, photodynamic therapy, tacalcitol and botulinum toxin type A.
Systemic retinoids are still the most effective treatment method, especially in patients with severe Darier's disease.
Psoriasis
Psoriasis is a common, chronic and benign disease of the skin that follows a course of flare-ups and periods of improvement, whose aetiology is not fully known and which is not life-threatening in most cases. Its extent and severity vary from patient to patient. Sometimes it appears in different clinical forms in the same patient over time. Our understanding of the pathogenesis of psoriasis has completely changed in the light of studies in recent years. Whereas it was previously accepted to be a disorder of epidermal differentiation with keratinocyte hyperproliferation, today it is accepted that a reaction in the form of epidermal hyperplasia develops as a result of immune system activation in focal areas of skin, resulting in epidermal hyperproliferation. The immunological event underlying the disease is reported to be chronic stimulation of T cells in the skin and a disorder in their communication with other cells. However, how and why these cells are activated is not known.
Pitting (thimble nail): This is the appearance of tiny pits on the nails. It can be seen in psoriasis, alopecia areata and eczema. Even if these diseases are treated, the pits may remain on the nails.
Onycholysis
Onycholysis is a physical finding in which the terminal nail plate separates from the underlying nail bed. It is seen in association with psoriasis, eczema, chronic paronychia, "yellow nail syndrome", thyrotoxicosis and repeated mechanical trauma, or for unknown reasons.
Splinter Haemorrhage
This is pinpoint bleeding from the capillaries in the nail bed, causing linear haemorrhages under the nail. It can occur in one or more nails. It can be located at the tip of the nail, in the middle or at the lunula. It can develop due to physical trauma (foreign body), drugs, skin diseases (Darier's disease, psoriasis, nail fungus) and systemic diseases (amyloidosis, antiphospholipid syndrome, leukaemia), or without any cause. It can develop spontaneously in people living at high altitudes. In the elderly it occurs normally at the tip of the nail. Simple cases without a cause are often on the left hand and the thumb. Painful splinter haemorrhages occur particularly in bacterial endocarditis and are an important nail sign.
Subungual haemorrhage, subungual haematoma: bleeding in the nail unit can be under the nail and around the nail. It is often caused by trauma and is observed in the big toenails. Cases not caused by trauma can develop due to systemic diseases or drug use. For example, anticoagulant, i.e. blood-thinning, drugs can cause bleeding. As subungual haemorrhage penetrates the inner part of the nail plate, over time it reaches the tip of the nail as the nail grows. Bleeding under and around the nail can cause permanent nail damage when it affects the nail matrix. In these cases it is extremely important to drain the haematoma by making small holes in the nail with a needle or laser.
Transverse Linear Lesions
Beau's lines: These are transverse linear depressions that appear on the nail. They appear on more than one nail, all at the same point, due to any disease severe enough to affect nail growth. Considering that the nail grows by 1 mm every 6–10 days, the time of the causative event can be determined from the distance of the depression from the nail bed. Apart from systemic diseases, trauma and exposure to cold in patients with Raynaud's disease can also cause Beau's lines.
Mees' lines: These are transverse white bands; they can appear on a single nail but mostly appear on more than one nail. In this picture the nail bed is normal, but the nail is microscopically fragmented because of disruption of normal growth due to the causative factor. The width of these lines is variable; as the defect is in the nail plate, it moves distally over time. In this way the time of the causative factor can be determined.
Clubbing
(Hippocratic fingers, watch-glass nails)
Clubbing was first described by Hippocrates in the 1st century BC; it can be acquired or congenital. Acquired clubbing is more common and is associated with pulmonary diseases in 80% of cases. In hypertrophic pulmonary osteoarthropathy, clubbing is accompanied by hypertrophy of the limbs and painful pseudo-inflammatory joint changes.
In clubbing, as a result of enlargement of the soft tissue distal to the nail, the angle between the nail plate and the proximal nail fold exceeds 180 degrees. The angle between the proximal nail and the finger (Lovibond's angle) flattens, producing "Schamroth's sign". This is the narrowing of the diamond-shaped gap that appears when the backs of the distal phalanges of corresponding fingers of both hands are placed against each other.
Secondary clubbing can be unilateral or bilateral. Unilateral clubbing is common in neurological (hemiplegia) and vascular diseases. Bilateral clubbing is observed in pulmonary, cardiac, gastrointestinal, infectious and endocrine diseases. Clubbing can accompany malignant diseases, especially lung and pleural malignancies. Apart from these, it can also be observed in lung diseases such as bronchiectasis, lung abscess, empyema, pulmonary fibrosis and cystic fibrosis, as well as in arteriovenous malformations or fistulas, coeliac disease, cirrhosis, inflammatory bowel diseases, congenital heart diseases and endocarditis.
Although the cause of clubbing is not fully understood, it is thought to arise from clusters of megakaryocytes and platelets that escape the filter in the pulmonary bed and pass into the systemic circulation, with the platelets releasing PDGF in the nail bed and causing periosteal changes. Some authors attribute it to increased local blood flow in local arteriovenous anastomoses. The increased blood flow is stimulated by changes in vascular dynamics caused by blood bypassing the capillaries. In clubbing associated with inflammatory bowel diseases, inflammatory changes mediated by the vagus nerve, fibrosis and possibly other autonomic pathways form the afferent part of the finger-clubbing reflex. Clubbing usually develops over years, but when it sometimes develops subacutely it can cause pain.
In a patient with new-onset clubbing, it is important to distinguish whether it is true clubbing or pseudo-clubbing. Pseudo-clubbing usually affects a single nail and is usually due to a subungual mass. At first glance the nail appears truly clubbed, but careful examination shows that the angle is normal. When clubbing is present, malignancy, especially bronchogenic carcinoma, must be ruled out.
Koilonychia
Koilonychia is the nail plate taking on a spoon shape as a result of increased transverse and longitudinal concavity. This change is a normal variant in children and returns to normal within a few years. Apart from this, it is also seen with trauma, exposure to petroleum-based solvents, nail–patella syndrome, and iron deficiency with or without anaemia. It has rarely been reported to accompany haemochromatosis. Spoon nails can also occur in patients with Raynaud's disease or lupus erythematosus, but in these it is not an isolated finding. When there is no obvious disease accompanying spoon nails, iron deficiency and haemochromatosis should be ruled out by measuring a full blood count, iron level and ferritin.
Onycholysis (Separation of the nail from its bed)
This is the separation of the tip of the nail from the nail bed. Diseases such as goitre, psoriasis, eczema and lichen, and antibiotics such as tetracycline, can often cause this condition. Sometimes this condition can be permanent.
Onychomadesis
Onycholysis describes the separation of the nail plate from the nail bed and/or hyponychium at the distal and lateral parts. Onychomadesis , on the other hand, is when this separation occurs at the upper (proximal) part of the nail plate, at the matrix.
4 clinical types have been described.
Type I: many fingers are involved; the nail is separated from the nail bed in a sharply demarcated half-moon shape.
Type II: only 1 finger is affected. There is a well-demarcated area opening towards the tip of the nail.
Type III: many fingers are involved. Initially there is a round yellow colour which later turns red, and this lasts 5–10 days.
Type IV, or photo-onycholysis: a bulla develops under the nail, after which onycholysis appears. This type of onycholysis develops in all types of porphyria. Among drugs, tetracycline, psoralens, fluoroquinolones, chloramphenicol, birth control pills and chlorpromazine also cause it. It appears either immediately or a few weeks after taking the drug.
Types of photo-onycholysis:
Type I: onycholysis occurs near the tip of the nail, and pigmentation is observed at the border of the onycholysis.
Type II: it occurs higher up the nail.
Type III: it is observed in the middle of the nail.
UVA is blamed in photo-onycholysis. With its convex structure, the nail acts almost like a lens, causing UV to be focused on the nail bed.
In addition, the absence of melanin and sebaceous glands in the nail bed makes this easier.
Onycholysis and onychomadesis can develop due to trauma, irritants and allergenic substances. They can also develop due to congenital and systemic diseases, drugs, tumours, fungal diseases or other skin diseases. Anatomically, there is normally no granular layer in the cell layers of the nail bed. In skin diseases such as psoriasis or lichen, formation of a granular layer in the nail bed causes the nail plate to separate from its bed.
Onycholysis can be of traumatic origin. As in the patient below, pressure from the 2nd toe on the big toenail causes onycholysis over time.
It is also observed in thyroid diseases, especially in excess thyroid hormone ("thyrotoxicosis"). This is called "Plummer's nails" and usually starts on the 4th and 5th fingers of the hand.
Causes of onycholysis of the nails:
Amyloidosis and multiple myeloma Pellagra
Anaemias Pemphigus
Bronchiectasis Porphyria
Lung cancer Pregnancy
Psoriatic arthritis Mycosis fungoides
Diabetes Raynaud's phenomenon
Drugs Reiter's syndrome
Scleroderma Histiocytosis X
Secondary and tertiary syphilis Leprosy
Vitamin C deficiency Lupus erythematosus
Yellow nail syndrome Neuritis
Onycholysis that develops without the causes listed above is called simple onycholysis.
Onycholysis develops more often on the fingernails. It most often develops due to irritants and chemicals, trauma and fungus.
Treatment:
- First, all factors that increase onycholysis and onychomadesis are eliminated.
- Fingernails and toenails should be kept short.
- Trauma to the nails should be avoided.
- The patient is asked to stay away from irritant chemicals.
- Irritants and excessive contact with water that may increase these problems should be avoided. For 12 months, powder-free vinyl gloves should be worn for wet work and contact with water, but cotton gloves must always be worn underneath them.
- "Candida albicans" is often observed on the nail in onycholysis. For this, fluconazole, ketoconazole and itraconazole can be used.
- In onycholysis, the nail is cut back to the upper border of the onycholysis, and then a lotion-like product containing "ciclopirox" is applied to the nail twice a day for 6–12 weeks.
- Contact with acidic fruit and vegetables should also be limited.
- In particular, contact with thinners, petroleum products, paints and metal polishes should be avoided.
- All nail cosmetics should be avoided for 2 months. Formaldehyde-free cosmetics should be preferred.
- Acetone should not be used on the nails. Nail polish removers containing acetate may perhaps be used.
- Hands and feet should be washed with lukewarm water, and harsh soaps should not be used for washing.
- Appropriate shoes should be chosen for the feet.
Melanonychia
Melanonychia describes the presence of melanin in the nail plate. It is usually observed as a longitudinal band on the nail. This band starts from the nail matrix and extends to the tip of the nail. Sometimes this pigment can involve the whole nail, and transverse bands may even be seen.
Normally there are melanocytes in the nail matrix, but they are not active. When they become active, they create these bands on the nail. This activation can range from a mole in the nail to malignant melanoma.
This activation may be due to racial factors. These bands are commonly observed in dark-skinned people. Apart from this, trauma, drugs and systemic diseases can cause this activation.
The number, colour and width of these bands vary.
In particular, the presence of melanonychia in a single nail should raise suspicion of malignant melanoma. In these cases, it is important to look for Hutchinson's sign on examination. Hutchinson's sign is the continuation of the nail pigmentation onto the skin around the nail. However, this sign may also be observed in some large moles located in the nail matrix.
Chemotherapy Nails
Cancer treatment, especially radiotherapy and chemotherapy, can lead to skin and nail problems depending on the person's response to treatment, the drug used and its dose, and sometimes other factors such as anaemia. These signs are not seen in everyone, and most problems will return to normal after treatment ends. Be sure to inform your doctor of all changes, especially significant skin changes, which can lead to permanent damage if not treated immediately.
Nail problems
The nails may darken or turn yellow, and breaking or cracking of the nails may be seen. For example, 6 or more cycles of high-dose taxane treatment can cause the nails to fall off. Transverse light and dark lines may form on the nails. Changes in nail shape (curling) may be seen, which is sometimes also related to iron deficiency and anaemia. Loosening of the nails or blood collecting under them can sometimes also cause pain.
Terry's nails
This is a common finding in liver cirrhosis, observed in about 82% of patients. Apart from this, it is also observed in chronic congestive heart failure and adult-onset diabetes. The leukonychia affects the whole nail except for a distal band of 1–2 mm. All nails are affected in the same way. Terry's nails are also commonly seen in normal individuals.
Half-and-Half Nails
They are found in 10% of patients with chronic renal failure. The leukonychia affects the proximal half of the nail, and all nails are affected. Half-and-half nails are also observed in normal individuals.
Splinter Haemorrhages
The shape of splinter haemorrhages results from the longitudinal orientation of the nail bed capillaries. When splinter haemorrhages appear simultaneously in most or all of the nails and are located in the proximal part of the nail plate, they point to a systemic disease.
In bacterial endocarditis, splinter haemorrhages are usually painful. Although their origin is not known, they are thought to result from micro-emboli. In trichinosis, 10–30% of patients develop painful splinter haemorrhages during the larval migration phase of the disease. In chronic mountain sickness and cyanotic congenital heart disease, splinters affect the whole nail; these are probably due to increased haemoglobin concentration. Drugs that affect the vessels in the nail bed (antithrombotic and anticoagulant drugs, chemotherapeutics, tetracyclines) can also cause splinter haemorrhages.
Median Nail Dystrophy
This is a longitudinal groove right in the middle of the nail plate with a fir-tree-like roughening around it. The grooving and ridging of the nail plate cause weakness and splitting at the tip of the nail.
Habit-Tic Deformity
There are parallel transverse depressions on the nail. It develops due to repeated trauma inflicted by the patients themselves.
Lamellar Nail Dystrophy
The nail splits horizontally into layers. The free edge of the nail is layered like filo pastry. As well as frequent contact with water, trauma, manicures, nail varnishes and varnish removers are also implicated in the aetiology. It is common in women. Nail hardeners can be used. Oily varnish removers should be preferred.
Ingrown Toenail
An ingrown toenail usually occurs on the big toe. As the nail grows, it tends to dig into the skin on one or both sides, and as a result of the inflammation that develops, the tissue at the edge of the nail also advances over the nail.
Nails are normally formed in the part at the nail root, beneath the skin, called the germinal matrix, and grow forwards over the upper part of the toe we call the nail bed. Long nails should be cut as straight as possible.
Sometimes the tips of the nail dig into the skin at the sides and start a reaction like a foreign body; sometimes the nail can become embedded not only at the corners but along the whole nail bed. In both cases the first signs are pain and swelling. There may be bleeding at the site of ingrowth, or infection may develop with pus. If left untreated, the inflammation may spread to the bone (osteomyelitis) and systemic infections may occur. Wearing shoes and walking can become very difficult.
An ingrown toenail can result from many causes; the most common cause is incorrect nail cutting. Cutting the nail too deep and cutting the nail tips curving too far inwards are the most common mistakes; in this case the regrowing nail will grow ingrown. Other causes of ingrown toenails are:
- the nail growing directly inwards instead of outwards
- wearing very narrow or pointed shoes
- thickening of the nail
- trauma to the toe or directly to the nail (such as stubbing, or something heavy falling on it)
- fungal infections
- obesity
- excessive sweating of the feet
- some congenital anomalies
- certain other diseases such as hyperthyroidism, diabetes, acromegaly, rheumatoid arthritis and gout
- in bedridden patients, covers such as quilts and blankets being wrapped too tightly.
Ingrown toenails can be prevented by avoiding many of these causes.
Symptoms of Ingrown Toenail
The most common symptoms are severe pain, infection, swelling, redness and sometimes pus. Diagnosis is normally made by examination alone. In some special cases, if it is suspected that the inflammation has spread to the bone, an X-ray may be needed. If there is a lot of inflammation, a wound culture may be needed to choose an appropriate antibiotic.
Treatment of Ingrown Toenail
An ingrown toenail with bleeding, pus or swelling must be shown to a doctor. People with ingrown toenails often delay seeing a doctor and present at a more advanced, painful stage. Trying to treat an ingrown toenail oneself when it first occurs can result in increasing pain, progression of the ingrowth to a level requiring nail removal, and infection; especially in those with circulatory disorders, arteriosclerosis and diabetes, the infection can progress and lead to complications such as bone infection, gangrene, and amputation of the toe or even the foot.
In the treatment of ingrown toenails not requiring surgery:
-Softening the nail by soaking it in a warm salt-water bath
-Placing a small piece of gauze with antibiotic cream under the ingrown part
-Reducing pressure on the nail by avoiding shoes and wearing sandals or open slippers
-Using antibiotics if there is significant infection
-Methods such as foot hygiene and care are applied.
The doctor will teach the patient how to place a piece of sterile gauze with antibiotic cream and how often it should be changed. In cases presenting early, non-surgical treatment is sufficient. It is important that the nails are cut straight and that the corners are not curved inwards. The main principle in treating an ingrown toenail is to allow the nail to grow beyond the length of the toe without digging in again; for this, it is important to create the natural groove between the nail edge and the toe and to "make way" for the nail to grow properly.
Surgical Treatment of Ingrown Toenail
In cases of severe ingrowth, tissue overgrowth and infection, surgical intervention will be required for treatment. The surgical treatment method varies from person to person according to the degree and type of ingrowth. In an ingrown toenail, partial removal on the ingrown side, i.e. removal of part of the nail, or removal of the whole nail may be required. As well as removing the nail, removal of the overgrown tissue and revision of the nail bed are very important. In severely curved nails, the edges of the germinal matrix where the nail is produced can be destroyed with certain chemicals, cautery or laser to prevent the nail from regrowing from those parts. In very advanced cases, the whole germinal matrix can be destroyed and the nail eliminated completely (nail ablation).
Nail removal is a painless procedure performed under local anaesthesia. Patients can walk home after the procedure. Much more important than nail removal is the care of the newly growing nail and ensuring that it grows normally. For this reason, follow-up by a doctor until a normal nail has formed again is important. If there is also a fungal infection alongside the ingrown toenail, this must also be treated. If the choice of shoes is wrong, this should also be corrected according to the doctor's advice.
Pincer Nail
There is an increase in the transverse curvature of the nail. The curvature increases further towards the tip of the nail. At the tip, the edges of the nail are embedded in the soft tissue like a pair of pincers.
Clinically, pincer nail is a very painful nail disorder. Cutting the nail and wearing shoes become very difficult. Psoriasis, soft tissue tumours, bone tumours and beta-blocker drugs can lead to pincer nail. As well as pain, it can cause recurrent infections.
Pachyonychia Congenita
Pachyonychia congenita (PC) is also known as Jadassohn-Lewandowsky syndrome. It is inherited in an autosomal dominant manner. Mutations are observed in the keratin genes KRT6A, KRT16 and KRT17.
It is a disorder of keratinisation presenting with thickening and roughening of the fingernails and toenails, keratoderma of the palms and soles with excessive sweating, follicular keratosis, and white plaques (leukokeratosis) on the oral mucosa, especially on the tongue. It appears in the first 6 months after birth, and the clinical signs remain for life.
In more than 97% of these patients, thickening of the nails is observed at birth or afterwards. A hard brownish-yellow material accumulates under the nails in the distal 2/3 of the nails. This accumulation distorts the shape of the nail, giving it a pincer appearance.
Keratoderma of the palms and soles is observed in 40–65% of cases. Apart from keratoderma, excessive sweating is observed. In some cases, painful blisters may develop on the palms and soles.
Follicular keratosis, especially on the hips, knees and elbows, is seen in 65% of cases.
Hair loss (alopecia) is seen. The hair is sparse and coarse.
White plaques, often in a linear pattern, on the edges and upper surface of the tongue and on the cheeks can be seen in 75% of cases, and skin cysts in 35%.
Dyskeratosis and cataracts may be seen in the eyes.
Intellectual development problems have been reported.
Leukokeratosis of the eardrum causes hearing loss.
With advancing age, PC can affect the larynx and oesophagus in the throat. This causes the voice to deepen with age.
Subtypes of PC have been defined according to the clinical picture.
PC Type I: clinically, nail involvement, leukokeratosis of the oral mucosa and keratoderma of the palms and soles are observed.
PC Type II: in this type, in addition to Type I, blisters on the hands and feet, excessive sweating, natal teeth (being born with teeth) and skin cysts such as steatocystoma multiplex are seen.
PC Type III: in addition to Type II, angular cheilosis, corneal dyskeratosis and cataracts are seen clinically.
PC Type IV: in addition to Type III, lesions of the larynx in the throat with deepening of the voice, intellectual disability and hair anomalies are seen.
Dyskeratosis Congenita
Dyskeratosis congenita is a rare disease affecting many parts of the body, presenting with nail dystrophy, pigmentation of the neck and chest and oral leukoplakia. It is also known as congenital dyskeratosis.
Individuals with this disease are vulnerable to conditions that impair bone marrow function. They may cause certain deficiencies in the production of blood cells. In such cases, affected individuals may develop aplastic anaemia, and myelodysplastic syndrome may be seen.
Other signs and symptoms seen in dyskeratosis congenita are as follows:
- Pulmonary fibrosis
- Certain eye disorders as a result of blocked tear ducts
- Reduced bone mineral density
- Degeneration of the hip and shoulder joints
- Narrowing of the urethra and painful urination in men
There is a severe special form of the disease called Hoyeraal-Hreidarsson syndrome. Its incidence is one in a million.
When its genetic basis is examined, it has been found to result from a deficiency or mutation in the TERT, TERC, DKC1 or TINF2 genes. These genes are involved in producing proteins in the structure of telomeres. Dyskeratosis congenita is inherited in an X-linked recessive manner.
Yellow Nails
This rare condition is a chronic disease affecting all 20 nails; nail growth is slowed or stopped (<0.2 mm/week). Slowed nail growth, a feature of yellow nail syndrome, causes the nail to thicken; total nail production is unchanged, but the slowed growth has changed the orientation of the cells. The longitudinal curvature of the nails is increased and the cuticle is lost. Onycholysis and onychomadesis, which cause the whole nail to separate, are also common. Yellow nails are usually observed together with lymphoedema and respiratory diseases such as chronic bronchitis, bronchiectasis or sinusitis, pleural effusions, internal malignancies, immunodeficiency syndromes and rheumatoid arthritis. In rheumatoid arthritis, it is common in those taking thiol-group drugs (sodium aurothiomalate). Although yellow nails occur in those with impaired lymphatic drainage of the limbs, this theory has not been proven. Functional defects in the lymphatics have been found by lymphangiography in affected individuals, which explains why the changes in the fingers improve when respiratory problems are treated. The relationship between nail changes and the lymphatics is also supported histopathologically. Ectatic lymphatic vessels have been shown in the nail bed. Some researchers suggest that yellow nails are due to protein leakage resulting from increased microvascular permeability, which is responsible for the condition often occurring together with hypoalbuminaemia, pleural effusion and lymphoedema. Diagnosis is made by the typical clinical findings; although there is no effective treatment, vitamin E (1200 IU/day) and pulse itraconazole treatment are recommended.
Twenty-Nail Dystrophy (Trachyonychia)
Twenty-nail dystrophy (TND) or trachyonychia is used to describe nail surface anomalies that cause roughening of the nail surface. This nail symptom can be a manifestation of various inflammatory dermatoses such as alopecia areata, lichen planus and psoriasis. A definitive diagnosis can be made by histopathological examination of nail material showing findings typical of lichen planus and psoriasis, or spongiotic changes in alopecia areata.
Patients with TND can be studied in 2 groups.
1- Those with signs of alopecia areata (AA) in their history or on examination
2- Those with nail findings only
Epidermolysis Bullosa
Although nail changes are common in epidermolysis bullosa (EB), the findings are not specific to EB subtypes. Severe and recurrent blister formation can cause permanent nail loss. In junctional progressive EB, the nail findings generally precede the other findings of the disease. The nails appear thick and short. Recurrent periungual and subungual haemorrhagic bullae can form.
Periungual Verruca Vulgaris
About 70% of cutaneous warts are verruca vulgaris. The causative agent is usually HPV type 2. It is more common in children. The lesions are few or many, 1–10 mm in size, rarely larger, round or polygonal, firm, skin-coloured papules with an uneven surface. They cause no subjective symptoms. Red-black dots caused by thrombosed capillaries are characteristic. They occur most often on the backs of the hands and on the fingers. 65% can resolve spontaneously within 2 years, without scarring. Tuberculosis verrucosa cutis should be considered in the differential diagnosis. The backs of the hands and fingers are the most common sites. Manicures, nail biting and similar trauma make it easier for warts to localise at the nail edge of the finger. Rarely, verruca vulgaris can also occur on the oral mucosa.
Although rare, epidermoid carcinoma can develop on verruca vulgaris.
Filiform (thread-like) warts, a variant of verruca vulgaris, take the form of a thread-like hyperkeratotic projection rising from a horny base, and are located especially on the face, scalp, eyelids and sides of the nose.
Junctional Melanocytic Naevus
Junctional naevi, a type of acquired mole, generally form up to the age of 30. These moles, which at most reach about half a centimetre, are shades of brown or black. Although their risk of turning into cancer is lower than that of congenital moles, they should still be kept under observation.
Pyogenic Granuloma
This is one of the acquired anomalies of the skin. It is also called "lobular capillary haemangioma".
It is usually seen as a single, red, raised, fast-growing lesion. It bleeds easily.
Its size ranges from 0.5 to 2 cm. It is usually under 1 cm.
It is more common under the age of 2, and its frequency decreases with age.
As well as on the skin, it can also be seen on mucous membranes such as inside the mouth.
A quarter of patients have a history of trauma before it forms. It can also develop in connection with hormonal processes. In addition, it can develop with the use of isotretinoin, used in acne treatment, and other drugs such as capecitabine or indinavir.
A special form seen in the mouth in women, especially during pregnancy, is called "pregnancy epulis" and is usually located on the gums. It regresses spontaneously after pregnancy.
There is usually a vascular structure in the centre with thickened skin around it. They grow very fast, bleed easily and are often crusted. They tend to be located on the head, face and fingers.
Treatment
Surgical or laser treatments are used.
- Argon and CO2 Laser
1–2 sessions are carried out 3–4 weeks apart. - PDL
Its effect is very good when performed with diascopy.
PDL can be applied to pyogenic granuloma as 2–3 overlapping pulses. 6.5–9.0 J/cm2 is applied.
Laser treatments are preferred more because bleeding is controlled and no scar remains afterwards.
Because the lesions are of varying thickness, pyogenic granuloma may not always be suitable for laser treatment, but it can be treated with laser after the papular part has been removed surgically. Apart from this, early-stage treatment and the use of diascopy are also factors that increase treatment success. Although 1064 nm Nd:YAG, 585 nm PDL and IPL systems are used in treatment, an increased risk of pyogenic granuloma development has been reported in about 1% of patients treated with PDL. Non-vascular residual remnants of the lesion can be treated with CO2 laser.
Glomus Tumour
Because of a glomus tumour or paraganglioma, which usually grows slowly, patients present to a doctor with complaints of a long-standing swelling in the neck. Sometimes the presence of this tumour is detected on neck ultrasound, CT (computed tomography) or MRI (magnetic resonance imaging) scans carried out for other reasons, and the patient, who until then was unaware of the tumour, starts looking for a doctor.
A glomus tumour does not cause complaints such as pain, dizziness or severe restriction of neck movement. It grows silently over the years without making itself known.
What are the symptoms of a glomus tumour?
Because of a glomus tumour or paraganglioma, which usually grows slowly, patients present to a doctor with complaints of a long-standing swelling in the neck. Sometimes the presence of this tumour is detected on neck ultrasound, CT (computed tomography) or MRI (magnetic resonance imaging) scans carried out for other reasons, and the patient, who until then was unaware of the tumour, starts looking for a doctor.
A glomus tumour does not cause complaints such as pain, dizziness or severe restriction of neck movement. It grows silently over the years without making itself known.
What are the causes of a glomus tumour?
As with many benign tumours, the cause of glomus tumours is not clearly known. In some patients there is hereditary transmission, meaning the formation of the tumour is due to genetic causes.
Which doctor should you see if a glomus tumour is suspected?
In our country, the diagnosis and treatment of glomus tumours is generally undertaken by ear, nose and throat (ENT) doctors experienced in head and neck surgery. However, some cardiovascular surgeons also deal with the treatment of such tumours in the neck region.
A glomus tumour is typically located at the bifurcation where the carotid artery divides in two.
In addition, less commonly, it can arise from the upper part of the "vagus nerve", which leaves the skull and extends to the chest and abdominal cavities. Although this area lies slightly above the area from which the carotid body tumour (glomus caroticum) arises, distinguishing the two tumours can be difficult even with investigations such as MRI and CT. Exactly where the tumour arises from is often determined during surgery.
How is a glomus tumour diagnosed?
When a glomus tumour or other tumours of the neck region that can be confused with glomus tumours (schwannomas arising from nerves, lymph gland enlargement, etc.) are suspected, one or more radiological investigations such as ultrasound, CT and MRI are usually performed.
Some doctors also require imaging methods such as angiography (imaging of the blood vessels), MR angiography or CT angiography to examine the relationship of these tumours with the blood vessels in more detail.
Although needle biopsy is usually used for diagnosis in other parts of the neck, needle biopsy is generally not performed around the carotid artery where this tumour is located, because vital structures such as blood vessels and nerves are packed tightly into a small area.
MRI, CT and ultrasound images often cannot clearly distinguish between tumours located in this region. As needle biopsy or open biopsy is not performed in this region, the definitive diagnosis of a glomus tumour is often made during surgery.
How Is a Glomus Tumour Treated?
Thanks to today's advanced anaesthesia and surgical techniques, these tumours can be treated with low rates of "complications" (undesirable outcomes that may result from a medical or surgical procedure).
As with almost all benign tumours in the head and neck region, the main treatment for a glomus tumour is surgery. That is, the tumour is removed from the body through an operation on the neck performed under general anaesthesia. The essential aim of this operation is to remove the tumour completely without damaging the carotid artery and the important nerves in that area.
Fibromas Around or Under the Nails (Koenen Tumours)
This is a specific sign of this disease (tuberous sclerosis). It is seen more often on the toes and in women.
One of the systems primarily affected by tuberous sclerosis is the central nervous system. The first sign related to the central nervous system is usually epilepsy, which is seen in more than half of cases. Tuberous sclerosis should be investigated in unexplained epilepsy under the age of five. There is progressive intellectual disability, especially in those with epilepsy. In addition, intracranial calcifications and intracranial tubers may be present and may cause symptoms such as paraplegia and hemiplegia (paralysis).
Retinal phakomas in the eye, seen in 10–40% of cases of TS, are a diagnostic sign. Signs in other systems are rare; angiomyolipomas in the kidneys, lung cysts, bone cysts and rhabdomyosarcoma of the heart may be seen. The prognosis is poor in progressive neurological involvement and involvement of other systems. There is no effective treatment. Surgical excision or laser can be applied to the skin lesions.
Subungual Exostosis
Subungual exostosis is an acquired, benign, solitary, rare bone tumour appearing at the distal end of the terminal phalanges. It results from outward growth of normal bone tissue. Although it was long considered a variant of osteochondroma, in recent years these two diseases have been thought to be clinically, histopathologically and radiologically distinct entities. It is more common in adolescents and young adults. 80% occur on the big toe.
Squamous Cell Cancer
This is a skin cancer arising from the squamous cells of the skin. It develops and progresses quickly and can spread. It usually appears on sun-damaged skin and in sun-exposed areas. The most common sites of squamous cell skin cancer include the lower lip (in cigarette or pipe smokers), the outer ear and the back of the hand. Sun protection starting from childhood is the most important factor in preventing the development of squamous cell carcinoma. Annual dermatological check-ups are very important for early diagnosis, especially for people with high sun exposure.
When diagnosed early, treatment options such as surgery, electrocauterisation, cryotherapy, radiotherapy and immunomodulatory drugs are evaluated and applied on an individual basis.
First of all, physical protection methods such as hats and umbrellas are recommended. Children need to be carefully protected from the sun. It is important to use sunscreen at the appropriate dose and frequency.
Acral Lentiginous Malignant Melanoma
Malignant melanoma (MM) is one of the aggressive tumours of the skin and mucosa, arising from melanocytes. The incidence of MM is increasing faster than that of other types of cancer. In addition, the mortality rate is higher in older people. For this reason, early diagnosis and treatment are important in terms of mortality.
In MM, three features on dermatoscopic examination are important in distinguishing benign from malignant: asymmetry, an atypical pigment network and blue-white structures. If 2 or 3 of these criteria are positive, removal of the lesion and histopathological examination are recommended. In addition, there are many evaluation algorithms such as pattern analysis, the ABCDE rule, the Menzies method and the seven-point checklist.