REFERAT

NAIL DISORDER AND HOW TO HANDLE

Nurlaela 121677714133
Rahmatia Anwar 121677714147

Supervisor
dr.Sukma Anjayani, M.Kes, Sp.KK
 INTRODUCTION
Nail is one of dermal appendages which has horn
layer that located in the top of fingers, the function is
to help fingers for holding something, besides it also
used as mirror of beauty. Nail plate is formed by
ceratin cells which has two sides. One side is
connecting to air space and the other is not.
Nail disorder can be caused by infection either
bacteria or fungus, such as paronikia which become
secunder infection and onikomikosis or psoriasis,
liken planus, alopesia, nail sign of systemic disease
and hereditary or congenital.
 NAIL ANATOMY
Nail matrix
Nail wall
Nail bed
Nail grove
Nail root
Nail plate
Lunula region
Eponychium (cuticle)
Hiponychium
TYPES OF NAIL DISORDER
 PARONYCHIA

Paronychia disease is an infection of the skin and soft

tissue that surrounds a toenail or fingernail. Nail disorder
is can be suddenly appear (acute paronychia) or step by
step (chronic paronychia)
Acute paronychia is most commonly due to
Staphylococcus aureus infection and typically affects a
childrs fingernail. Predisposing factors include biting or
sucking the nail, and occupational trauma.
Chronic paronychia is usually caused by mechanical or
chemical traumas damages the cuticle and permit
penetration of irritan and alergenic environtmental
substance under the proximal nail fold, causing an
inflamatory reaction of the nail fold and matrix.
Cont..

The symptoms: a small

collection of pus forms under
the skin next to the nail, or
underneth the nail itself. The
area arround the nail is tender,
red and mildly swollen the
cuticle is missing and the skin
arround the nail feels moist or
boggy. Often only one nails Figure : acute paronychia
is affected.
treatment:
Acute topical antibiotic. If an
abscess has developed, incision
and drainage must be
performed.
Chronic protection the hand
from trauma, topicalsteroid, dan
topical antiseptic
Figure : chronic paronychia
 ONYCHOMYCOSIS

Onychomycosis is a fungal infection of the nail. Fungi

include Trichophyton, Microsporum and
Epidermophyton species.
There are 4 clinical types of onychomychosis: Distal
lateral subungual onychomycosis (DLSO), Superficial
white onychomycosis (SWO), Proximal subungual
onychomycosis (PSO), Candida onychomycosis
 Figure : Distal subungual onychomycosis

a. Distal lateral subungual onychomycosis (DLSO)

This infection mostly develope in matrix nail start from
distal to proksimal through lateral distal side or plate nail
lateral
Clinical presentation: hyperkeratosis subungual,
onycholysis (removal of nail plate from nail bed), and
thickening of nail. Subungual is the basic place of fungus
and infectious bacteria which can cause dyscoloration in
the nail plate that become yellow.
 Figure : Superficial white onychomycosis

b. Superficial white onychomycosis (SWO)

This is nail disorder happen because of fungus that directly
infect the superfisial nail plate.
specific description which can be seen in this case is the
appeareance of white patches which clearly appear above
the nail plate. Gradually, nail will become rough, benign and
brittle.
 Figure : Proximal subungual onychomycosis

c. Proximal subungual onychomycosis (PSO)

This case generally found in AIDS sufferers, if this case
happen to someone, it can be said that someone already
get infection from HIV
This infection will develope distally in whole surface of
nail. Thie clinical presentation is hyperkeratosis and
onycholysis proximal, also the destruction of phrocymal
nail plate.
 Figure : Chronic mucocutaneous candidiasis

d. Candida onychomycosis
This type is found in chronic mucocutaneous candidiasis
suffer which is caused by 70% by C. albicans
Cont..

Treatment
Griseofulvin is fungistatic and needs to be taken in relatively
high dose for one year or more for toenails
ketoconazole : it should be controled because the potencial of
hepatotoxicity
Terbinafine : dose of 250 mg daily for 12 weeks for toenails
and 6 weeks for fingernail.
Itraconazole : dose of 100 mg twice daily for 12 weeks or a
pulse dose of 200 mg twice daily for 1 week each month for 3
months
Fluconazole: dose of 200 mg once weekly until the nail are
normal, a period of time which could be up to 12 month for
toenails and 9 month for fingernail
Topycal antifungal drugs : cyclopirox
 NAIL LICHEN PLANUS

Liken planus in the nail can be appear without skin

disorder. The changes in the nail can be like longitudinal
crack, nail flodaway which blow up around (nail
pterigium), sometime anonikia. Nail plate will become
thin and this type can also contact with nail plate. The
arrangement of nail must be handle seriously, beause
liken planus able to crush the nail.
 Figure : Nail matrix lichen planus before and after
treatment with systemic steroids.

Treatment
oral or intramuscular treatment with systemic
steroids. intralesional corticosteroid injections
should be considered in patients with involvement
of fewer than three digits.
 NAIL PSORIASIS
Clinical presentation: psoriatic pitting, onycholysis with
erythematous border and salmon patches of the nail bed.
Onycholysis is actually the most common manifestation of nail
psoriasis and may affect both fingernails and toenails. In
fingernails the presence of an erythematous border along the
onycholytic area is diagnostic for nail psoriasis. In toenails,
onycholysis is usually combined with subungual
hyperkeratosis.
Salmon patches (oil drop sign) appear as yellowred areas of
discoloration in the center of the nail or bordering an
onycholytic area.
Other common but rather aspecific signs include splinter
hemorrhages and paronychia
Figure : Nail psoriasis, onycholysis surrounded by
an erythematous border and salmon patches of
the nail bed.

Figure : Psoriasis of the toenails producing

subungual hyperkeratosis and onycholysis.
Cont..

Treatment
instruct patients to avoid trauma
infliximab 5 mg /kg
Intralesional steroid : triamcinolone acetonide 2.5
5.0 mg/mL in saline for which they can be
injected in the proximal nail fold every 48 weeks.
Acitretin at low dosages (0.20.3 mg/kg/day) for 4
to 6 months
topical treatment with calcipotriol, combination of
calcipotriol and betamethasone, or tazarotene
 DARIER DISEASE

Darier disease is brittle nail and crockery nail which

signe with the changing of longitudinal color and
hyperkeratosis under the nail
Involvement of the nail matrix result in
onychorrhexis, with splitting and fragillity as well as
red and white longitudinal streaks
 Figure : Nail changes in Dariers disease
Treatment
Discuss how to avoid triggers (heat, sweating, friction) and
minimize UVB-induced exacerbations.
Emollients containing urea or lactic acid.
Soap substitutes and topical antiseptics.
Moderate or potent topical corticosteroids with topical
antibiotics.
Topical retinoids: isotretinoin (0.05%, 0.1%),
tretinoin, tazarotene gel, adapalene 0.1% gel.
 ALOPECIA AREATA
Alopecia areata is a condition that caused both hair
loss and nail changes, although not necessarily at
the same time. The nail changes caused by alopecia
areata are pitting, thinning of the nail plate and
sometimes red lunula.

Treatment
Topical and intralesional triamsinolon 2,5-3
mg/ml at monthly intervals.
Figure : Pitting of the nail in alopecia areata

Figure : The red spot in the lunula

 NAIL SIGN OF SYSTEMIC DISEASE
1. Koilonychia
Commonly called spoon nails, occurs when the free edge
of the nail is everted. Koilonychia can be idiopathic or
associated with a variety of conditons such as anemia,
occupational and traumatic injury or endocrine
condotions such as hypo- and hyperthyroidism.

Figure : Koilonychia or spoon nails

2. Clubbing finger
Is characterized by increases in distal finger tip
mass and increased longitudinal and horizontal
curvature of the nail plate. Clubbing affects the
fingernails and toenails. The clubbing sign means
that something is not going well for the body.
Found on condition : Infection, neoplastic and
pulmonary inflammation (bronchiectasis,
emphysema), cardiovascular disorders such as
congestive heart failure, and congenital heart /
disease associated with heart valves.
Figure : Lung cancer: clubbed fingers

Figure : Clubbing of the toenails

3. Beaus line
Is transverse depression in one or more nails that
result from a growth arrest in the nail matrix following
a systemic illnes or severe trauma.
Most common among these are drugs (especially
chemotherapy), high fever, viral illness, surgery, and
peripheral ischemia

Figure : Beaus lines of systemic illness.

4. Half-and-half nails are describe as having a proximal
white-half and a distal red / brown half due to changes
in the nail bed color. Half-and-half nails occur as a sign
of renal insufficiency and uremia. The nails revert to
normal when renal function normalized or following
renal transplant.

Figure : Half-and-half nails

5. Terrys nails are describe as a milky white nail that
extend from the proximal nail fold to the narrow red-
brown band in the area of onychodermal band on the
nail. The lunula is usually obscured by the white.
Pressing on the nail plate alters the appreance and
color of the nail. Terry's nails have been associated
with congestive heart failure, liver disease and even
aging.

Figure : Terrys nails

6. Splinter Hemorrhages : Hemorrhages splinter: are nail changes
characterized by small red/brown lines in the nail bed. They are
asymptomatic and usually occurs in the distal portion of the nail.
They are the result of a tiny amounts of blood in the longitudinal
grooves of the nail bed. There is a long list of less common
conditions in which splinter haemorrhage are found including
trichinosis, endocarditis, embolic events, blood dyscrasias, and
with certain medications.

Figure : Infective endocarditis: splinter hemorrhage

7. Systemic Lupus Erythematous : nail fold erythema and
telangiectasis.

Figure : Nail fold of Systemic lupus erythematosus

8. Yellow nail syndrome is characterized by nails that are
yellow, slow growing, with absent lunula and cuticle.
The nails may thicken and appear curved and become
opaque so that the lunula is obscured. The conditions
associated with yellow nail syndrome are lymphedema,
respiratory conditions including bronchiectasis,
sinusitis, and pulmonary effusion

Figure: Yellow nail syndrome

 Treatment of nail sign due to
systemic disease more likely to
the base etiology of the disease.
 HEREDITARY AND CONGENITAL NAIL
DISORDER
1. The ectodermal dysplasias (ED) are a group of inherited
disorders that share in common developmental defects
involving at least two of the major structures classically held to
derive from the embryonic ectodermhair, teeth, nails, and
sweat glands. Nail changes may be associated with
hypotrichosis, hypodontia, and hypohidrosis. Most commonly
the nails are short, thickened, and hypoplastic.

Figure : Nail of Ectodermal dysplasia

2. Epidermolysis bullosa: is a hereditary disorder and nail
abnormalities are a common feature in most subtypes of
epidermolysis bullosa (EB). Trauma undoubtedly contributes
to the development of nail dystrophy and for this reason the
great toenails are more often severely affected. It is
characterized by Partial or total anonychia, pachyonychia,
subungual/periungual hemorrhagic blisters, and periungial
erosions with granulation tissue.

Figure: Epidermolysis bullosa simplex nail dystrophy

3. Pachyonichia Congenital is an autosomal dominant
genodermatosis characterized by painful keratoderma, nail
thickening, oral leukokeratosis, and epidermal cysts nails are
thickened, very difficult to trim, darkened, and with an
increased transverse curvature. Nail thickening is a
consequence of nail bed hyperkeratosis and is more evident
on the distal half of the nails, which have an upward angling

Figure: Pachyonychia congenita

4. Nail patella syndrome is a rarely genetic disorder, which
involves the organs that come from ectodermal and
mesodermal. Nail abnormalities in this disease may
involve all fingernails or may be limited to the thumbs,
which are always the most severely affected digits. Nail
hypoplasia is usually more marked in the medial portion of
the nail. The shape of the lunula is typically triangular.

Figure : nail abnormalities in nail patella syndrome

5. Congenital malalignment of the hallux is the most common
cause of ingrowing (ingrown) nails and is usuallydiagnosed
when the child starts to walk. The digit is painful and the
toenail often shows Beaus lines and onycholysis. Congenital
malalignment may be unilateral or bilateral. Spontaneous
improvement may occur, and most children do not have
symptoms by the age of 2 years.

Figure : Congenital malalignment of the hallux.