Applied aspects of nail
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Applied aspects of nail
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Applied aspects of nail
- 1. ALTERATIONS IN THE NAIL PLATE DR. YUGANDAR
- 2. KOILONYCHIA Reverse curvature in longitudinal & Transverse axes giving a concave dorsal aspects of nail Signs most prominent in great toe & thumb Iron def anemia in adults Common feature in infancy great toe nail,persistence indicative of deficiency of cysteine rich keratin in Trichothiodystrophy
- 3. KOILONYCHIA -Spoon shaped deformity -Normal Convexity replaced by Central Concavity -Surrounded by Distal & Lateral Margins -Lichenplanus,hypothyroidism, hemochromatosis,20- nail dystrophy
- 5. BEAUS LINES Single horizontal ridge by horizontal lines of darkened cells and linear depressions It is the result of any interruption in the protein formation of the nail plate trauma, illness, malnutrition or any major metabolic condition, chemotherapy
- 6. BEAU’S LINES Multiple transverse ridging Chemotheraphy with Breast Cancer
- 8. BEAU’S LINES
- 9. TRACHYONYCHIA (20-NAIL DYSTROPHY,SANDPAPERED NAILS) Rough surface affecting all nail plates,idiopathic forms k/s 20 nail dystrophy k/a Sand Blasted Nails in French means grey,roughened surface Alopecia areata, Psoriasis,Lichen planus Histology shows spongiosis & lymphocytic infiltrate
- 10. ONYCHOMADESIS(NAIL SHEDDING) Detachment of the nail plate from proximal nail fold,d/t severe insult that produces arrest of nail matrix activity Proximal detachment of nail Most often traumatic
- 11. ONYCHAUXIS GREAT TOE NAILS GROSSLY THICKENED WITH TRANSVERSE RIDGING ( ONYCHAUXIS ) Nail thickening d/t subungual scales Subungual hyperkeratosis psoriasis,onychomycosis,e czema
- 12. ONYCHIA • Inflammation of the nail matrix • It is accompanied by pus formation • There is Inflammation within the nail plate
- 13. ONYCHOCRYPTOSIS (INGROWN TOE NAIL) Lateral ingrowing usually affects hallux, great toe Teenagers,Young adults,congenital malalignment of big toes nails often present Ppt by improper nail cutting and hyperhidrosis Growth of granulation tissue undergoes epithelialization DD: Multiple Periungual Pyogenic granulomas d/t retinoids,ART drugs
- 14. ONYCHOCRYPTOSIS :TREATMENT Prevention through patient education Removal of embeded spicule Uplifting of lateral nail plate Chemical – 80% Phenol,Laser or Surgical removal of Lateral Matrix in severe cases Granulation tissue prevented by topical antibiotics & steroids,
- 15. ONYCHOCRYPTOSIS (INGROWN NAILS) Also known as ingrown nails May affect either the fingers or toes The nail grows into the sides of the flesh & may cause infection
- 16. WASHBOARD NAILS
- 17. HABIT TIC DEFORMITY Dystrophic nails Transverse ridging Absent of cuticle Excoriation of Proximal nail fold
- 18. ONYCHORRHEXIS Brittle nails,split vertically, peel or have vertical ridges. The result of heredity, the use of strong solvents in the workplace or the home, including household cleaning solutions. Lichen Planus,tumours which compromise vascular supply
- 19. ONYCHORRHEXIS Thinning of Nail plate Longitudinal ridging & fissuring Mild Longitudinal ridging is characteristic of Ageing
- 20. ONYCHOGRYPOSIS Claw-type nails that are characterized by a thickened nail plate Often the result of trauma This type of nail plate will curve inward, pinching the nail bed and sometimes require surgical intervention to relieve the pain.
- 21. ONYCHATROPHIA It is an atrophy or wasting away of the nail plate which causes it to lose its luster, become smaller & sometimes shed entirely Injury or disease may account for this irregularity
- 22. PINCER NAILS Painful abnormality of nails Toe >> finger nails a/w subungual exostosis Distal nail plate over curved & compresses subungual tissue
- 23. BRITTLE NAILS a vertical splitting or separation of the nail plate layers at the distal (free) edge of the nail plate characteristic of the natural aging process. overexposure to water and chemical solvents such as household cleaning solutions
- 24. Brittle nail
- 25. PACHYONYCHIA CONGENITA AD,very rare Hypertrophy of nails occurs a/w nail bed hyperkeratosis PC 1: Normal by birth,Progressively discoloured,thicken more on hands,Palmo- plantar hyperkeratosis & warty lesions at knee,elbows,buttocks,Defect Keratins 6a & 16 PC 2: Less severe nail thickening & Keratosis, a/w hamartomas,Kinky scalp hair,epidermal cysts,Defect keratins 6b & 17
- 27. ALTERATIONS IN NAIL SIZE
- 28. ANONYCHIA ABSENCE OF ALL OR PART OF ONE OR SEVERAL NAILS Congenital: Mutation in R- Spondin 4 gene Transient : Due to nail shedding Acquired: Due to scarring of nail matrix Trauma,Burns,Surgery, Lichenplanus. Epidermolysis bullosa- irreversible nail loss
- 29. ANONYCHIA It is a/w DOOR syndrome,AEC syndrome,EEC syndrome,TOOD syndrome Anonychia atrophica : it is an acquired nail dystrophy,Permanent,secondary to nail matrix damage
- 30. ANONYCHIA Congenital absence of nails in child
- 31. MICRONYCHIA Nails Smaller Uni or Bilateral Identifies in Iso- Kikuchi syndrome,Zimmerman-Laband syndrome,Turners syndrome
- 32. MACRONYCHIA Naila are larger Uni Or Bilateral It is a/w Macrodactyly as in Vonrecklinnghausens disease,Maffucci syndrome,Klippel-Trenaunay-Weber syndrome
- 33. POLYNYCHIA Existence of two or more separate nails on one digit Rare Congenital anomaly Lawrence-Moon-Biedl syndrome
- 34. POLYNYCHIA
- 35. RACKET NAILS AD Girls > Boys Thumbs >> Other fingers Epiphyses of terminal phalanx of thumb closes prematurely by age of 7- 10yrs,normally at 13-14 yrs Distal phalanx of affected thumb is shorter & wider than normal Affected nails are opaque,short with loss of normal curvature Acquired: cong syphilis,acro osteolysis
- 36. RACKET NAILS
- 37. NAIL PATELLA SYNDROME AD Nails partially or totally absent Linkage b/w locus controlling disorder & ABO blood group LMX1B gene plays imp role,located on long arm of ch 9 Tetrad constitutes Nail dystrophy,Hypoplastic or absent patellae,Elbow dysplasia,Iliac horns Thumb >> other finger Affected nails 1/3 or 1/2 of normal size
- 38. NAIL PATELLA SYNDROME Lunula are triangular or V shaped Bilateral Post Iliac horns on x-ray Pathognomonic Prenatal diagnosis by USG Possible Other features Lester iris,Open angle glaucome,Palmoplantar hyperhidrosis, Scapular hypoplasia
- 39. NAIL PATELLA SYNDROME Traingular Lunula
- 40. ISO KIKUCHI SYNDROME Nails of index finger small or absent Unilateral or bilateral Miconychia is MC presentation Terminal bifurcation of distal phalanx is characteristic feature
- 41. DOLICHONYCHIA Nails appear narrow & long Normally ratio b/w length & breadth of nail is 1 + 0.1 In these condition about 1.9 Identified in Ehlers danlos syndrome,Marfans syndrome
- 42. CIRCUMFERENTIAL NAILS Nails are Tubular Congenital seen in siblings Nails may cover all sides of one or more fingers
- 43. CONGENITAL MALALIGNMENT OF BIGTOE Lateral deviation of long axis of nail growth relative to distal phalanx one big toe or both Medial deviation is rare Nails discoloured & thickened,often traingular in shape MC identified in Monozygotic & Dizygotic twins Nail grows temporarily fast than bone of hallux,Realignment occurs when bone growth catches up with nail post natally
- 44. PERIODIC SHEDDING Nails of great toe MC affected AD One or more nails shed repeatedly Regrowth of nail incomplete,defective Trauma from ill fitting shoes is MC cause of repeated shedding of nails in sports persons
- 45. ALTERATIONS IN NAIL SHAPE
- 46. CLUBBING Increased Transverse & Longitudinal nail curvature with hypertrophy of soft tissue components of digital pulp Hyperplasia of fibrovascular tissue at base of nail gives Rocked nail appearance Lovibonds angle, Curths angle, Schamroth’s window Also K/A Hippocratic nails ,Watch glass nails
- 47. CLUBBING Patient with cystic fibrosis
- 49. CLUBBING Increased blood flow through vasodilated plexus of nail unit vasculature > Vessel hyperplasia Altered Vagal tone Microvascular infarcts PDGF may responsible for vascular changes Painful clubbing indicative of periostitis associated with HPOA,characteristic of thoracic malignancy Pachydermoperiostosis : idiopathic,Puberty,a/w spade like thickening of foot & hands
- 50. CLUBBING SHELL NAILS RACKET NAILS Similar to clubbed nails Girls with bronchiectasis around 5 yrs age Avulsion of nail plate reveals atrophy of nail bed instead of hypertrophy noted in true clubbing Broad & Shortened nails usually seen thumb & great toes Similar to clubbed nails D/T stubby appearance Arrest in distal phalangeal formation
- 51. CLUBBING Lovibond angle : angle at junction of nail plate & proximal nail fold Normally less than 160 degrees Clubbing angle is more than 180 degrees
- 52. CLUBBING Curth’s angle : Angle at Distal interphalangeal joint Normally 180 degrees Clubbing diminished less than 160 degrees
- 54. RACKET NAIL WITH CLUBBING RACKET NAILS
- 55. DISEASES OF NAIL BED
- 56. PSORIASIS Multiple nail pits on dorsal nail plate Oil staining of nail bed Distal Onycholysis
- 57. PSORIASIS Rough surface (Trachonychia ) Distal onycholysis Oil Staining
- 58. PSORIASIS Punctate Leukonychia Pathognomic Traumatic subungual haemorrhage
- 59. PSORIASIS Oil staining Longitudinal ridging Distal onycholysis Adherence of cuticle to distal nail plate
- 60. PSORIASIS Spongitic Pustule seen in Epidermis Absence of Granular layer,Acanthosis of Epidermis,Vascular Changes
- 61. LICHEN PLANUS Nail involvement seen in 10 % of patients with LP Nail thinning,ridging & fissuring Cicatricial out come ( Dorsal Pterygium ) Yellowish discolouration Onycholysis
- 62. LICHEN PLANUS Middle Finger : Proximal nail fold and matrix caused trachonychia,Longitudin al ridging,pterygium Index Finger : Destruction of Nail Plate & Matrix with anonychia
- 63. LICHEN PLANUS Involvement of nail matrix with pterygium Scarring Pt had Hepatitis C virus with erosive lichen planus
- 64. LICHEN PLANUS Involvement of nail matrix Thinning of thumbnail plates
- 65. LICHEN PLANUS : Lichenoid infiltrate of nail bed and distal nail matrix * ,Nail plate
- 66. LICHEN PLANUS HYPERKERATOSIS & SUPERFICIAL LYMPHOCYTIC INFILTRATE BAND LIKE SUPERFICIAL LYMPHOCYTIC INFILTRATE ALONG WITH VACUOLAR DEGENRATION
- 67. DARIER-WHITE DISEASE (KERATOSIS FOLLICULARIS) Nail involvement in 96% cases Red or white longitudinal streaks ending in a V shaped notch Streaks indicative of nail thinning Subungual hyper keratotic papules in hyponychium Histologically similar to acantholysis of skin in addition of multinucleated giant cells,epithelial hyperplasia seen A case of SCC developing in chronic case of darier disease also noted
- 68. DARIER-WHITE DISEASE (KERATOSIS FOLLICULARIS) Longitudunal streaks ( red & white ) Distal subungual hyperkeratotic papules Wedge shaped fissuring of nail plate
- 69. DARIER-WHITE DISEASE (KERATOSIS FOLLICULARIS) White and Red Longitudinal streaks Distal notching
- 70. RED LUNULA Erythema of all or part of the lunula may affect all digits, but most prominently the thumb Dotted red lunulae have been reported in psoriasis and alopecia areata red lunula seen in a single digit-Local disturbance of vascular flow- Benign tumour Glomus tumour & Subungual myxoid cysts MC tumours.colour vary from blue & red
- 71. YELLOW NAIL SYNDROME The nails are yellow due to thickening,rarely green tinge possibly due to secondary infection There is increased transverse & longitudinal curvature,loss of cuticle & Lunula obscured AD A/w lymphoedema at one or more sites and respiratory or nasal sinus disease
- 72. YELLOW NAIL SYNDROME Histologically dense fibrous tissue replacing Subungual stroma with numerous ectatic epithelium lined vessels,FB reaction may be seen Obstruction of lymphatics by dense stroma leads to the abnormal lymphatic function found in the affected digits Recurrent pleural effusions,Ch bronchitis, bronchiectasis,increased incidence of malignant neoplasms,nephrotic syndrome
- 73. YELLOW NAIL SYNDROME Nails grow at slower rate 0.1-0.25 mm/week ( normal rate 0.5mm/week )
- 74. YELLOW NAIL SYNDROME Diffuse Yellow to Green of nails Nail thickening Excessive curvature of from side to side
- 75. YELLOW NAIL SYNDROME Treatment : - Oral & Topical Vit E - Oral & Topical Zn - Pulse Itraconazole 400mg daily /week/month - Treatment of Chronic infection - Complete reversion of nail changes may occur spontaneously
- 76. HUTCHINSON’S SIGN Brown black periungual pigmentation Possible sign of nail melanoma First described by Hutchinson ,Pigmentation of proximal nail fold in a/w longitudinal melanonychia Also identified in melanocytic naevi
- 78. GREEN NAIL SYNDROME Greenish black discolouration d/t Pyocyanin by P. aeruginosa Exposure to water,detergents & soaps Barbers,Bakers & Dish washers DD: Melanoma,Aspergillus,Melanocytic naevus Rx:Aminoglycosides,Acetic acid for 1 to 4 months
- 79. MEE'S LINES Transverse white lines that run across the nail, following the shape of the nail moon Uncommon after acute/severe illness, Arsenic poisoning
- 80. MEE'S LINES
- 81. BROWN – GRAY NAILS
- 82. CYANOSIS A bluish discoloration visible at the nail bases patient with severe hypoxemia or hypoperfusion.
- 83. CYANOSIS
- 84. HALF-&-HALF NAILS K/a Lindsay's nails Look for an arc of brownish discoloration May occur in a small percentage of people who have ch renal failure Other causes systemic diseases & nutritional deficiencies
- 86. SPLINTER HAEMORRHAGES Looks like a splinter underneath the nail virtually 100% diagnostic of Sub-acute Bacterial Endocarditis (SBE) A bacterial infection affecting the valves of the heart. Occasionally caused by Trichinosis, a parasitic infection caused by eating raw or undercooked Pork.
- 88. MELANONYCHIA vertical pigmented bands or nail 'moles‘ a sudden change in the nail plate could indicate a malignant melanoma or lesion. Commonly occur in dark-skinned people, and are normal Seek physicians care ,If you suddenly see this change in the nail plate.
- 89. MELANONYCHIA
- 90. LEUKONYCHIA WHITE DISCOLOURATION OF NAILS True Leukonychia: Inherited disorder,all nail affected,milky porcelian white nails Subtotal Leukonychia : Proximal 2/3rd white rest pink d/t delay in keratin maturation Transverse Leukonychia: k/a Mees lines reflect systemic disorder,chemotheraphy,poisini ng Punctate Leukonychia: White spots of 1-3 mm size,Manicure,alopecia areata Apparent Leukonychia: Changes in nail bed responsible for white appearance Terry’s Nails: white proximally,normal distally,seen in old age,chronic renal failure,afterchemotheraphy,cirr hosis,cardiac failure,histology shows Inc vessel wall thickness & Melanin deposition Muehrcke’s paired white bands : bands parallel to lunula in nail bed with pink in b/w white lines,seen in hypoalbuminaemia
- 91. LEUKONYCHIA White nails in distal free edges
- 92. TERRY'S NAILS The nail looks opaque and white, but the nail tip has a dark pink to brown band. May accompany cirrhosis, congestive heart failure, adult- onset diabetes, cancer or ageing.
- 94. ECZEMA OF THE NAIL It affect the eponychium, nail plate and bed It causing pitting and onycholysis. This is very rare
- 95. Eczema
- 96. HANG NAILS Caused by minor injury or constant irritation through biting. The cuticle splits and appears as a small spike. Hot oil manicures and regular use of a cuticle oil will help. The spike can be clipped so it does not catch on things.
- 97. EGGSHELL NAIL Nail plate is thin and abnormally flexible chronic illness of systematic or nervous origin It curves at the free edge and the nail plate can separate from the nail bed
- 98. ONYCHOLYSIS DISTAL OR LATERAL SEPARATION OF NAIL FROM NAIL BED Psoriatic onycholysis considered as a reference point for other forms PO-typically distal,variable lateral involvement,area of separation appear white or yellow due to air beneath the nail,sequestered debris & glycoprotien exudate Isolated islands of onycholysis present as Oil spots , salmon patches
- 99. ONYCHOLYSIS Idiopathic -Painless separation of nail from its bed -Overzealous manicure, wetting,cosmetic solvents -Condition starts at tip of nail,spreads to distal one third of nail bed -Colonization of candida albicans & pseudomonas pyocyanea -Affected nails grow very quickly,more in women, Secondary - Psoriasis,trauma,fungal infections,dermatitis,hypo thyroidism,yellow nail syndrome,shell nail syndrome - Photoonycholysis : treatment withpsoralens,doxycyclin e,demethylchlortetracycli ne,retinoids,anti cancer drugs
- 100. ONYCHOLYSIS Distal onycholysis Loss of cuticle Psoriasis may be cause
- 101. ONYCHOLYSIS Most commonly associated with external trauma to the nail Nail plate separates from the nail bed
- 102. ONYCHOLYSIS The subungual space may be filled with hyperkeratotic debris Distal nail bed separated from the nail plate in 2 nails.
- 103. ONYCHOLYSIS Treatment : - Patient advised cut away loosened nail & apply local steroid with antibiotics ( prevent keratinisation of nail bed,that slows reattachment of nail) - Gentamicin eye drops for pseudomonas infection - 2% thymol in chloroform for preventing infection - Milton regimen : soaking finger tips several nights week in venegar or sodium hypochlorite solution for 5 mins for prevention of recurrence
- 104. ONYCHOMYCOSIS A fungal or yeast infection which results in Onychomycosis, can invade through a tear in the proximal and lateral nail folds as well as the eponychium. This type of infection is characterized by onycholysis with evident debris under the nail plate. It normally appears white or yellowish in color, and may also change the texture and shape of the nail. The fungus digests the keratin protein of which the nail plate is comprised. As the infection progresses, organic debris accumulates under the nail plate often discoloring it.If left untreated, the nail plate may separate from the nail bed and crumble off.
- 105. ONYCHOMYCOSIS (TINEA UNGUIUM) White spots that can be scraped off the surface, or long yellowish streaks within the nail substance. It attacks the free edge & moves towards the matrix
- 106. ONYCHOMYCOSIS
- 107. TINEA UNGUIUM – NAIL INFECTION
- 108. ONYCHOMYCOSIS DSO Distal subungual hyperkeratosis and onycholysis involving most of the nail bed of the great toenails; these findings are usually associated with tinea pedis.
- 109. Onychomycosis
- 110. ONYCHOMYCOSIS NAIL CLIPPINGS SHOW SEPTATE HYPHAL ELEMENTS PROVEN TO BE TRICHOPHYTON SP WITH IN NAIL PLATE KERATIN 90 % Toe nail infections with Trichophyton,Microsporum,Ep idermophyton sp PAS staining most sensitive test Stain reveals fungal organisms located in lower stratum corneum Distal subungual Onychomycosis is MC form,caused by T.rubrum It invades hyponychium & LNF finally yellow,onycholysis,sub ungual hyperkeratosis T.mentagrophytes identified in superficial white OM,located
- 111. ONYCHOPHAGY Bitten nails, often no free edge is visible Nails look ragged and distorted skin and nail bed can be exposed and raw
- 112. ONYCOPHOSIS Refers to the growth of the horny epithelium in the nail bed In other words a callus like growth on the nail plate
- 113. ONYCHOGRYPHOSIS Elderly,Commonly toenails,usually Hallux Favored by trauma Impairement of peripheral circulation and innervation Nail acquires typical Ram’s Horn shape d/t asymmetric growth Thick,hard,yellow brown nails
- 114. ONYCHOPTOSIS Periodic shedding of one or more nails, either in whole or parts This condition may follow certain diseases such as syphilis
- 115. PARONYCHIA Paronychia is associated with separation of the seal between the proximal nail fold and the nail plate that provides entry for bacteria and leads to a localized infection of the paronychial tissues of the hands. Symptoms may include inflammation, swelling & scaling
- 116. PARONYCHIA An infectious and inflammatory condition of nail folds. Infection is bacterial Ch paronychia may weaken defences and increase the risk of developing a fungal infection of the nail
- 117. PARONYCHIA The nail fold is erythematous, edematous, with early abscess formation, and is very painful.
- 118. Paronychia
- 119. PTERYGIUM Pterygium is the inward advance of skin over the nail plate, Usually as a result of trauma to the matrix due to a surgical procedure or by a deep cut to the nail plate Pterygium results in the loss of the nail plate due to the development of scar tissue Cortisone is used to prevent the advancement of scar tissue. Never attempt to remove pterygium -instead, consult a physician for advice and treatment NOTE: The 'true cuticle' is often referred to as Pterygium
- 120. PTERYGIUM Pterygium Inversum Unguis is an acquired forward growth of the hyponychium characterized by live tissue firmly attached to the underside of the nail plate, which contains a blood supply and nerves. Possible causes are systemic, hereditary, or from an allergic reaction to acrylics or solvents. Never use force to 'push back' the advancing hyponychium -- it is an extremely painful approach, and will result in a blood flow.
- 121. PTERIGIUM An abnormal winged like growth of skin (living tissue) on the nail plate The skin is slowly stretched and dragged along the bed caused by severe trauma such as warts, burns & blood circulation disorders.
- 123. SCABIES OF NAIL Commonly identified in crusted scabies Heaped up masses of keratin accummulate underneath the nail Subungual material contains abundant mites,source of infection Nails become dystrophic
- 124. SCABIES OF NAIL
- 125. SCABIES OF NAIL Sarcoptes scabiei present in distal subungual hyperkeratotic debris found in hyponychium Cause of persistent epidemics of scabies Norwegian scabies severe involvement of nail folds Scrapings of distal hyponychium- showing organism – Sarcoptes Scabiei
- 126. CANDIDA Candida parapsilosis account for 20% infections Candida common cause of Chronic paronychia,involve nail bed & nail plate in HIV Candida albicans major cause of hypertropic nail bed infection in paediatric patients with HIV
- 128. CANDIDA NAIL CLIPPINGS SHOW BUDDING YEASTS
- 129. PSEUDOMONAS Pseudomonas bacterial infection can occur between the natural nail plate and the nail bed Many people have been led to believe that the classic 'green' discoloration of this type of infection is some type of mold In actuality, mold is not a human pathogen. The discoloration is simply a by- product of the infection and is caused primarily by iron compounds
- 130. PSEUDOMONAS Pseudomonas thrive in moist places; it feeds off the dead tissue and bacteria in the nail plate, while the moisture levels allow it to grow The after effects of this infection will cause the nail plate to darken and soften underneath an artificial coating
- 131. PSEUDOMONAS The darker the discoloration, the deeper into the nail plate layers the bacteria has traveled. If the bacteria has entered between the nail plate and the nail bed, it will cause the same discolorations and may also cause the nail plate to lift from the nail bed.
- 133. ALOPECIA AREATA First sign in 18% cases,More in children Pitting of nails,When pits uniformily distributed on multiple nails,they often arranged in lines horizontially or vertically in a geometrical design k/a Glen-Plaid or Scotch-Plaid Pattern
- 135. ASSESSING NAIL DISORDERS Social History Footwear Medical History Physical exam Nail Assessment Special Investigations
- 136. SOCIAL HISTORY Smoking Occupation Recreational Activities Places of residences (Qsld)
- 137. FOOTWEAR Occupational Recreational Historical May need to inspect footwear
- 138. MEDICAL HISTORY Need to conduct a review of systems (ROS) Dermatological Conditions important eg psoriasis, atopy, Multi-System Disorders eg RA, SLE, DE, CREST Cardiac/Pulmonary Problems Medications review Surgical Review Genetics review
- 139. PHYSICAL EXAMINATION Vascular macro/micro circulation Neurological Deficits? Dermatological Below Knee Gait Assessment
- 140. SUBJECTIVE NAIL ASSESSMENT Events of Note How long has problem been present? Is it getting better or worse? Is it of concern to the client? Is pain present? If so need to evaluate pain What previous treatments have been attempted? Professional OTC Folk Need to follow up if any of these answers is positive
- 141. OBJECTIVE ASSESSMENT OF NAILS Number of nails affected? Hands involved? Colour changes Extent of colour changes Extent of general changes Presence of toe deformity Presence of local exostosis May need to examine other areas Scalp, elbows, knees
- 142. SPECIAL INVESTIGATIONS Nail Specific Biopsy Microscopy (KOH test) Culture X-Ray Blood Tests Further Vascular/Neurological Testing Cardiac Evaluation Genetic Testing
- 143. COMMON AETIOLOGIES Trauma Infection Fungal Bacterial Systemic Disorders Direct Indirect Neoplasms
- 144. THANK YOU PLEASE SHOOT QUESTIONS AT dryugmd@gmail.com