NAIL EXAMINATION – ANOTHER PROF. S.N. CHAKRABORTY’S MASTERCLASS

 

I have, a few weeks back, introduced you to Prof. S.N. Chakraborty, our mercurial Professor of Medicine in King George’s Medical College, Lucknow. If you have somehow missed that blog, please click: https://surajitbrainwaves.blogspot.com/2024/03/remembering-prof-s-n-chakraborty-by-his.html

He was a very kind hearted person, an astute clinician and an outstanding teacher. We, in our Alma mater, knew him as an encyclopedia of Medicine and patients revered him as God’s incarnation. Always smiling, his very presence was reassuring to all patients and relatives, residents and students. Once at 8 AM he walked in our lecture theatre and in his inimitable way asked what we wanted to study that day. Unfortunately, it was only on the day before, we had a dermatology class on nail infections, that left us totally confused, so almost in unison everyone said – “examination of the nail”. And so it was instantly decided that’s what we will be studying.

In his sagacious way the Professor said “your body communicates when something is wrong. The color and state of your fingernails can let you know when something is going awry inside your body. Sometimes they can be minor vitamin deficiencies and other times more serious conditions. These changes can be subtle, or blatant and it’s worth noting any differences because many diseases are reflected on your fingertips. As always these are warning signs and it’s important not to rely solely on your nails for a health check. See the entire patient, and what is more important, listen to his story!”

1. Red nails

If your nails go from a pink shade to a darker red, you might have heart disease. If the redness extends to the sides of your nails and cuticle, this might be a sign of the autoimmune disease Lupus. If one nail fold is red and painful it is paronechoea.

 

2. Unusually white nails

This phenomenon is often called Terry’s nails and has three possible explanations. One is that you have developed a fungal nail infection, often accompanied by reddened or dark fingertips. Another reason could be that your nails have begun to detach from the nail bed and the blood supply is interrupted. Thirdly, this is also a side effect of chemotherapy. Terry’s nails also might indicate that you have a more severe illness like anemia, iron deficiency, diabetes, liver cirrhosis, organ failure or hyperthyroidism.

 

3. Thick or overgrown nails

If the nails are growing thicker and faster than usual, your patient might be suffering from a serious fungal nail infection. You might also notice that the nails have become discolored. These symptoms are common results of having either psoriasis or arthritis.

 

4. Detached from the nail bed

When nails begin to detach from the nail bed without trauma or pressure, you might have a hormonal imbalance. Similarly, if your nails have separated, you might be suffering from hyperthyroidism – a condition where your thyroid gland is releasing too many hormones into your system.

 

5. Dark vertical stripes

Many people ignore stripes on their fingernails because they don’t cause any pain however some can indicate very serious illnesses. If you find that you have dark vertical stripes, known as linear melanonychia. This could be a sign of Subungal Melanoma, an aggressive form of skin cancer that only affects the nail bed.

 

6. Blue nails

If you find your nails suddenly have changed to a blue or purple tinge, it’s likely you have developed hypoxia, a lack of oxygen, often triggered by poor circulation to your feet, ears, and hands. Impaired circulation is easily reversible and is not a serious health issue unless it goes untreated. Blue nail or Cyanosis can be central or peripheral. Central cyanosis is caused by diseases of the heart or lungs or by abnormal haemoglobin types like methemoglobin or sulfhemoglobin etc. This is seen commonly as bluish or purple discoloration of tongue and linings of the mouth. Peripheral cyanosis results from decreased local blood circulation in the peripheral organs, arms and legs. This is commonly seen if the arterial blood stagnates too long in the limbs and loses most of its oxygen. Limbs appear bluish and are usually cold to touch. Peripheral cyanosis is most intense in nail beds. Warming may resolve the cyanosis.

Cyanosis shows up as the levels of deoxygenated blood rises in the small blood vessels of the fingers and toes. This may be seen in heart failure, shock (sluggish or slowing of blood circulation with severe loss of blood pressure), exposure to cold temperatures and diseases of blood circulation. Causes of central cyanosis in new-borns can either be in the heart or in the lungs. In the heart the are termed cyanotic heart diseases which include conditions like Transposition of great arteries, Fallot’s trtralogy, Total anomalous pulmonary venous return, small or hypoplastic left heart, and Truncus arteriosu. In the lungs the causes can be birth injury or asphyxia, respiratory distress syndrome, pneumothorax, pulmonary edema, meconeum aspiration, diaphragmatic hernia, pleural effusion, and trachea-oesophageal fistula. In adults constriction of blood vessels of the limbs, fingers and toes. This could be due to cold exposure, Raynaud’s phenomenon, spasm of the smaller skin capillaries or arteries called acrocyanosis, erythrocyanosis occurring in young women and as side effects of beta blocker drugs taken for high blood pressure.

 

7. Dents or Depressions

If you start seeing dents or depressions on the surface of nails this might be a sign of eczema, psoriasis, or reactive arthritis, a form of arthritis that like Lupus, finds your immune system attacking your joints. More than half of psoriasis sufferers experience nail depressions or dents.

 

8. Discolored nails

Nails should naturally by a healthy pink color and when you notice them altering shades you should take note. If they turn brown, this may indicate that the patient has a thyroid disease or is malnourished. Green nails indicate a severe fungal nail infection, nail psoriasis or even jaundice, tuberculosis, sinusitis, or lympheodema. If your patient is taking prescription drugs like anti-malarial pills, you might find grey tinged nails.

9. Spoon nails

This is called Koilonychia, a condition known for causing nails to become excessively soft and appear scooped out, much like a spoon. This symptom commonly indicates hemochromatosis, a liver condition where there is too much iron being produced in your system. Spoon nails also commonly indicate hypothyroidism. There are other diseases such as heart disease, anemia and impaired blood flow that are associated with this phenomenon.

 

10. Brittle nails

Characterized by thin, frail, crumbling nails this common nail problem often indicates a deficiency in vitamins, with vitamin B7 being the usual culprit. This can be easily reversed with multivitamin supplement. Frail nails are also often associated with nail psoriasis, thyroid disorders, or fungal nail infections. Clinically, there are three types of nail fragility: lamellar onychoschizia, onychorrhexis and superficial granulation of keratin. Lamellar onychoschizia, also known as lamellar dystrophy, is characterized by the presence of fine horizontal layers that crack and peel easily from the free margins. Onychorrhexis is defined as longitudinal splitting and fissuring of the superficial nail plate, often seen in elderly population. Superficial granulation of keratin presents in the distal nail plate. It is characterized by white-yellow discolouration and striations. The keratins in the nail plate undergo an exfoliative process resulting in formation of patches. It may be caused by poor quality nail polish. Dermatological diseases like Psoriasis, Lichens, Eczema, nutritional deficiencies of Vitamins, Iron, Zink and Selenium and medications like anti cancer drugs, arsenic, retinoids are associated with brittle nail syndrome. 

 

11. White stripes

While dark striped nails usually indicate cancerous growth, white stripes are more commonly seen as indicative of a disorder. It usually indicates an imbalanced or a non-nutritious diet, lacking in proteins. This problem can easily be resolved with an increase in proteins rich foods such as fish, quinoa, nuts, seeds, and lean meats.

 

12. Curved nails or Clubbing

This condition is called nail clubbing and involves an unnaturally large nail bed, curving around the tips of the fingers. It is not an overnight condition and can take several years to form. The cause is often hypoxia, a lack of oxygen. This can be seen with cystic fibrosis, congenital cyanotic heart disease, and several other serious diseases like irritable bowel syndrome, liver disease, lung abscess, branchiactesis, AIDS and cardiovascular diseases like SABE, Cirrhosis of liver and Hodgkin’s Lymphoma. The tips of the fingers enlarge and the nails become extremely curved from front to back.

 

13. Loose nails

Loose nails not caused by injury can signify fungal nail infection, nail psoriasis, amyloidosis (excess protein in the blood), hyperthyroidism, sarcoidosis or Raynaud’s disease a.k.a. poor blood circulation. In rarer cases, severe allergies to some antibiotics are known to loosen nails from nail beds.

14. Blue nail base

If you find the nails are a white shade on a blue nail base, this might be a sign of a nutrient deficiency such as a lack of iron. When the nails are extremely white and the base blue or purple, this could denote a problem with the liver or pancreas. It is also a common symptom in the initial stages of diabetes when your body is not able to process and metabolize sugars correctly. 

 

15. Yellow nails

Usually, yellow nails are a sign of an unpleasant fungal infection. Yellow nails can also be indicative of more serious illnesses namely a lung problem, such as pleural effusion and emphysema.

16. Smelly, discoloured and irregular nails

Seen particularly in toe nails in over 50% of adults over 70 years of age and 10% of general population, these irregular, thickened, misshaped, discoloured, brittle, crumbly and foul

smelling nails are of Onychomycosis or fungal infection of nails. It may start as white or yellow spots on nail tips but as the fungal infection goes deeper into the nail it becomes discoloured, thick and brittle. Fungi thrive in damp and dark environment and so people working bare feet in wet conditions or wearing damp and sweaty boots suffer from onychomycosis.  

The Professor concluded with the advice “Nail conditions are not only aesthetic concerns, and nail changes may be a clue to an underlying systemic diseases or infection. Without timely treatment, nail diseases can continue to worsen and significantly impair performance of daily activities and reduce quality of life. Examination of the nails is essential at every medical visit, and may uncover important findings.”

Friends, as I was trying to salvage this lecture from my three decades and a bit old Medicine notes, the image of Prof Chakraborty, walking to and fro across the lecture hall, approaching the blackboard only to write the sub-headings of discussion and smiling all the time, as he would bring out one point after another, came and went in front of my eyes, as if it was only yesterday's lecture. I have only added the illustrations, to show you how apt his description was, and how easily he could communicate with us who were then near novices!