Nail Abnormality

Aka: Nail Abnormality, Nail Disorder, Nail Disease, Nail Shape Abnormality, Nail-Related Growths, Tumors Under or Around the Nail, Subungual Mass, Sunungual Neoplasm, Nail Growth Abnormal, Nail Abnormalities, Anonychia, Onychodystrophy, Onychogryposis, Onychotillomania, Dystrophic Nail, Nail Dystrophy, Dystrophia Unguium

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II. Definitions

  1. Anonychia
    1. Absent nails
  2. Chromonychia (see Nail Discoloration)
    1. Color changes of nails
  3. Koilonychia
    1. Spoon-shaped nails
  4. Onychodystrophy
    1. Degenerative changes of nail
  5. Onychogryposis
    1. Hypertrophic shape changes of nail
  6. Onycholysis
    1. Loosening or detachment of nail from nail bed
  7. Onychomadesis
    1. Spontaneous separation from nail matrix
  8. Onychomycosis
    1. Fungal Infections of the nail
  9. Onychophagia
    1. Nail biting
  10. Onychoschizia
    1. Splitting, horizontal layering of distal nail edge
  11. Onychotillomania
    1. Compulsive pulling or picking of nails
  12. Paronychia
    1. Inflammation of skin around nails

III. History

  1. Timing
    1. Acute or chronic
  2. Distribution
    1. Single Nail Abnormalities may result from infection, Trauma or lesions
    2. Multiple Nail Abnormalities may suggest systemic condition
  3. Nail care
    1. Nail polish
    2. Topcoat or basecoat
    3. Nail strengtheners, hardeners or conditioners
    4. Cuticle treatments or manicures
    5. Artificial or gel nails
    6. Tools used during nail care
  4. Exposures
    1. Occupational or hobby exposures to toxins, Trauma or infection risk
  5. Restricted diet
    1. Nutritional deficiency
  6. Past Medical or Family History
    1. Skin disorders (e.g. Psoriasis)
    2. Autoimmune Disorders
  7. Medications
    1. See Nail Discoloration for associated medication causes

IV. Exam

  1. Remove nail polish from all nails for the exam
  2. Examine all finger and toe nails
  3. Nail Plate
    1. Nail Discoloration
    2. Nail Pitting
    3. Nail Groove or Lines (e.g. Beau's Lines, Muehrcke's Lines)
    4. Nail plate thickness
  4. Skin and soft tissue
    1. Examine skin surrounding the nail
  5. Vascular lesions
    1. Apply lesion pressure (vascular lesions should blanch)

V. Findings: Nail Changes

  1. See Nail Discoloration
  2. Nail shape abnormalities
    1. Koilonychia
    2. Nail Clubbing
  3. Nail surface abnormalities
    1. Brittle Nail
    2. Nail Pitting
  4. Lines
    1. Transverse Nail Groove (Beau's Lines)
    2. Muehrcke's Lines (double diagnonal white lines)
    3. Longitudinal striations or bands
  5. Terry's Nails
    1. Leukonychia of proximal two thirds of nail
  6. Abnormal nail plate attachment
    1. Onycholysis
    2. Ingrown Toenail (Onychocryptosis)
  7. Vascular changes
    1. Nail Telangiectasias
    2. Nail Splinter Hemorrhages
  8. Infection
    1. Onychomycosis
    2. Acute Paronychia
    3. Chronic Paronychia
    4. Herpetic Whitlow
    5. Common Wart (Verruca Vulgaris)
  9. Trauma
    1. Nail Bed Laceration
    2. Subungual Hematoma

VI. Findings: Skin Disorder-Related

  1. Alopecia Areata
    1. Trachyonychia (Nail Longitudinal Striation, Twenty Nail Dystrophy)
    2. Leukonychia
  2. Eczema
    1. Transverse Nail Groove (Beau's Lines)
    2. Shiny nails or speckling of nails
    3. Paronychia
  3. Lichen Planus
    1. Longitudinal grooves/fissures
    2. Nail thinning
  4. Psoriatic Onychodystrophy
    1. Nail Pitting
    2. Onycholysis
    3. Subungual hyperkeratosis
    4. Nail brown discoloration (oil staining)
  5. Scleroderma
    1. Trachyonychia (Nail Longitudinal Striation, Twenty Nail Dystrophy)
    2. Splinter Hemorrhages
  6. Systemic Lupus Erythematosus
    1. Splinter Hemorrhages
    2. Red appearing lunula
  7. Chronic Dermatitis
    1. Nail Pitting
    2. Transverse Nail Groove (Beau's Lines)

VII. Findings: Growths under or around the nail

  1. Malignant Growths
    1. Squamous Cell Carcinoma (most common)
      1. Higher risk in older men, HPV 16 or 18, Tobacco Abuse, Trauma or Radiation Exposure
      2. May present with hyperkeratosis, Onycholysis, Dystrophic Nail plate or Subungual Mass
      3. Refer to dermatology for evaluation and often MOHS excision
    2. Bowen's Disease
    3. Subungual Melanoma
  2. Benign Growths
    1. Digital Mucous Cyst
    2. Digital fibrokeratoma
    3. Exostosis
    4. Glomus tumor
      1. Rare, soft tissue tumor seen in age 20 to 40 years old
      2. Presents with subungual tenderness, cold sensitivity and painful paroxysms
    5. Keratocathoma
    6. Pyogenic Granuloma
    7. Tendon sheath giant cell tumor
    8. Periungual or Subungual Wart
      1. See Common Wart
      2. Presents with periungual Papules and Plaques with small thrombosed vessels ("black seeds)

VIII. Diagnostics

  1. Nail clippings
    1. May be sent for culture (e.g. Onychomycosis)
    2. May be diagnostic of underlying disorder (e.g. Psoriasis)
  2. Bedside Ultrasound (POCUS)
    1. May identify lesions beneath the nail (e.g. Onychomadesis, retronychia, growths, abscesses)
  3. Dermoscopy (Onychoscopy)
    1. May be used with nonpolarized lenses (superficial structures) or polarized lenses (deep structures)
    2. May be useful in evaluating for autoimmune-related findings, pigmented lesion evaluation
  4. Punch Biopsy
    1. Perform Digital Block
    2. Two step biopsy (both sent for pathology)
      1. Punch Biopsy of nail plate
      2. Punch Biopsy of nail bed (with punch smaller diameter than for the nail plate biopsy)

IX. References

  1. Habif (1996) Clinical Dermatology, Mosby, p. 778-9
  2. Collins (2025) Am Fam Physician 111(2): 177-8 [PubMed]
  3. Leggit (2025) Am Fam Physician 112(4): 401-9 [PubMed]
  4. Tully (2012) Am Fam Physician 85(8): 779-87 [PubMed]

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