Are You Confident of the Diagnosis?
What you should be alert for in the history
Onycholysis refers to the physical sign of separation of the nail plate from the nail bed (Figure 1). Because of this separation, the portion of the nail plate that is not attached appears white. A greenish discoloration can sometimes be seen in onycholysis, and can represent concomitant Pseudomonas infection. .
Characteristic findings on physical examination
It is much more common to see onycholysis affecting the fingernails as opposed to the toenails.
Onycholysis can affect multiple nail units or a single nail unit. If multiple nail units are affected, a systemic cause is a more likely culprit. If a single nail unit is affected, a history of trauma can often be elicited in the clinical history.
In the evaluation of onycholysis, a nail clipping can be performed to evaluate for the presence of onychomycosis.
One must be aware that onycholysis affecting a single nail unit may be caused by an underlying tumor. If onycholysis of a single nail unit is not responding to therapy, a nail-unit biopsy should be performed.
If the onycholysis is caused by a fungal infection, fungi will be identified on nail clippings sent for histologic analysis. For other causes of onycholysis, nail clippings may be unremarkable, or may demonstrate yeast, which can be considered a secondary phenomenon.
Who is at Risk for Developing this Disease?
Onycholysis is caused by a breakdown of the normal adhesive properties of the nail unit. When the onychodermal band at the distal aspect of the nail unit is disrupted, onycholysis can occur. Trauma, frequent and prolonged exposure to water, and exposure to contact irritants are common precipitating factors. Onycholysis can also be caused by an allergic contact dermatitis from nail cosmetics. Many systemic medications have been associated with onycholysis; these are detailed below. Sometimes a specific cause or precipitating factor cannot be identified.
What is the Cause of the Disease?
The cause of onycholysis is a disruption of the normal adherence of the nail plate to the nail bed. There are a variety of causes.
Prolonged exposure to water in combination with repetitive minor traumas can cause this change. Cutaneous blistering disorders, such as pemphigus can affect all of the skin surfaces, including the nail unit, and cause a disruption in the nail-plate nail-bed connection.
Photoonycholysis, caused by the combination of ingestion of medications and exposure to sunlight, can cause onycholysis. If a tumor is present within the nail unit, this can cause a disruption of the normal anatomy of the nail apparatus, and result in onycholysis. Contact dermatitis caused by the use of nail cosmetics can also cause a disruption of the normal nail unit anatomy related to the inflammation present. Onycholysis can also be caused by a variety of dermatologic diseases that affect the nail unit.
Primary dermatologic disorders affecting the nail unit that can manifest as onycholysis include but are not limited to: psoriasis, lichen planus, Reiter syndrome, pachyonychia congenita, and autoimmune blistering diseases, including pemphigus variants, porphyria cutanea tarda, atopic dermatitis, and lichen striatus.
For other systemic associations, the pathophysiology of onycholysis has not been clearly established.
Systemic Implications and Complications
The list of systemic disorders associated with onycholysis is extensive. These disorders include: thyroid disease (hyper- and hypothyroidism), connective tissue disorders (including lupus erythematosus and scleroderma), diabetes mellitus, iron deficiency anemia, peripheral ischemia, pregnancy, and yellow nail syndrome, as well as others.
Medications associated with onycholysis include those with photo-induced associations, as well as those not associated with light exposure. Some medications with photo-induced associations include: tetracycline, doxycycline, minocycline, psoralens, chloramphenicol, fluoroquinolones, benoxaprofen, chlorpromazine, and oral contraceptives. Some medications associated with onycholysis not associated with light exposure include: chemotherapy (including doxorubicin, etoposide, paclitaxel, docetaxel, bleomycin, 5-fluorouracil, mitoxantrone), retinoids, and captopril, as well as others.
If the timing of a medication has a clear association with the onset of onycholysis, it is reasonable to try to discontinue the suspected cause; however, some medications, such as particular chemotherapy agents, may be required because of an underlying malignancy, despite the presence of onycholysis.
As an initial screen for associated systemic disorders, it is reasonable to check a complete blood count and iron panel (for iron deficiency anemia), an antinuclear antibody test (for connective tissue disorders), as well as a thyroid-stimulating hormone (for thyroid disorders).
A thorough history, focusing on precipitating factors, often identifies elements that can be addressed and improved. For example, if extensive wet work is performed as part of household chores, protection of the hands and nails can make a strong impact on the extent and duration of onycholysis.
If nail clippings demonstrate onychomycosis, standard treatments for this disorder should be implemented. The significance of yeast and treatment of it is controversial, but if signficant yeast is identified in nail clippings, a topical antifungal can be of benefit.
For persistent single nail onycholysis, a nail-unit biopsy should be performed, and treatment of an underlying malignancy, if detected, may improve the onycholysis, while postsurgical onycholysis may persist as a sequela of treatment. If symptoms or signs suggest an underlying tumor, nail-unit imaging could be considered, such as with magnetic resonance imaging (MRI) or x-ray of the nail unit.
A key intervention is to instruct the patient to clip back onycholytic nails to the point of attachment to the nail bed. Long onycholytic nails can act as a lever and, with minor trauma, cause further onycholysis to affected nails.
For wet work, the use of cotton gloves under vinyl gloves helps protect the hands, while the cotton gloves absorb sweat and prevent the hands from becoming macerated.
Nails with onycholyis have disrupted anatomy, and can be made worse with exposure to foods that are irritating. For this reason, the use of gloves is also helpful when manipulating foods such as citrus fruits and tomatoes.
Gloves should also be worn when the hands come in contact with harsh chemicals, such as turpentine, which patients may encounter as part of their occupation or hobbies.
It is important to avoid manipulating the cuticles, and to actively avoid the use of nail cosmetics, until the nails are back to normal.
Use of high-heeled shoes should be avoided if onycholysis affects the toenails.
Optimal Therapeutic Approach for this Disease
The treatment options listed above are generally introduced at the same time at the initial visit for the patient presenting with onycholysis. Most of the interventions involve behavior alterations, do not have side effects, and have only minimal risk to the patient.
The patient should be followed up on a periodic basis to assess for improvement, and to reinforce behavioral changes, which can have a positive impact on the onycholysis. Reminders to continue to keep the nails clipped back to the point of attachment to the underlying nail bed will help continued progress.
Topical antifungals, if employed, do not need to be continued for extended periods of time. While a good adjunctive therapy, most of the benefit is from behavioral changes, as well as the removal of dead space between the nail plate and nail bed, which occurs with nail clipping.
Unusual Clinical Scenarios to Consider in Patient Management
An important, but unusual, clinical scenario that the practitioner should keep in mind is longstanding onycholysis limited to a single digit. If the onycholysis is longstanding, and in particular has not improved after conservative management, an underlying neoplasm, such as a squamous cell carcinoma, should be considered, and a nail-unit biopsy performed to assess for an underlying malignancy.
When single digit onycholysis is associated with oozing and bleeding, this is especially concerning for an underlying malignancy. A higher level of concern should also be present when single digit onycholysis occurs in an older/elderly patient.
Another unusual clinical scenario to consider is the unusual circumstance when onycholysis is present on multiple digits, and is caused by a primary dermatosis affecting the nail unit, such as psoriasis, which is presenting as onycholysis only.
Dermatoses limited to the nail units are difficult to diagnose in general, as other cutaneous signs of the disorder are lacking. If multiple nails with onycholysis do not improve with conservative therapies, biopsy of the nail unit can be considered to assess for this unusual clinical situation.
What is the Evidence?
Daniel, CR, Daniel, MP, Daniel, J. “Managing simple chronic paronychia and onycholysis with ciclopirox 0.77% and an irritant-avoidance regimen”. Cutis . vol. 73. 2004. pp. 81-5. (The authors studied thirty-one patients with simple onycholysis, who were treated with ciclopirox 0.77% topical suspension for 6 to 12 weeks, after clipping the nails back, in combination with a strict irritant-avoidiance regimen. This combination therapy improved the onycholysis in 87% of patients, and 81.5% demonstrated total clearance.)
Daniel, CR, Scher, RK, Daniel, CR. ” Simple onycholysis”. Nails: diagnosis, therapy, surgery. vol. 18. 2005. pp. 97-8. (A concise, yet comprehensive, review of simple onycholysis and its management)
Daniel, CR. ” Onycholysis: An overview”. Semindermatol . vol. 10. 1991. pp. 34-40. (A comprehensive review of onycholysis that includes thorough listings of medications associated with onycholysis, systemic diseases associated with onycholysis, inherited causes of onycholysis, and a thorough discussion of treatment)
Nakatusi, T, Lin, A. ” Onycholysis and thyroid disease: Report of three cases”. J Cutans Med Surg . vol. 3. 1998. pp. 40-2. (This report describes two patients with onycholysis associated with hypothyroidism, which had been undiagnosed, and a third patient with onycholysis who developed the problem while undergoing therapy for hypothyroidism. The authors suggest that patients with unexplained onycholysis should be screened for asymptomatic thyroid disease.)
Hussain, S, Anderson, D, Salvatti, ME. “Onycholysis as a complication of systemic chemotherapy. Report of five cases associated with prolonged weekly paclitaxel therapy and review of the literature”. Cancer . vol. 88. 2000. pp. 2367-71. (An extensive review of previously published literature demonstrating the association of onycholysis with systemic chemotherapy. Includes five cases from the authors’ personal experience.)
Kechijian, P. ” Onycholysis of the fingernails: Evaluation and management”. J Amn Acad Dermatol . vol. 12. 1985. pp. 552-60. (A comprehensive review of onycholysis, which includes a detailed classification schema, listing of occupations associated with onycholysis, associated medications, dermatologic causes, as well as management strategies.)
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