What is a lump in the fingernail? Discover the various types of nail abnormalities, their causes, and how they can impact your health.

Types of Nail Abnormalities

Nail abnormalities encompass a wide range of issues that can affect the color, shape, texture, or thickness of the fingernails or toenails. Some of the common nail abnormalities include:

Beau Lines

Beau lines are depressions or grooves that run across the fingernail. They can occur after an illness, injury to the nail, eczema around the nail, during chemotherapy, or due to nutritional deficiencies.

Brittle Nails

Brittle nails are a common result of aging, but they can also be caused by certain diseases and conditions, such as low levels of zinc and iron, or thyroid problems.

Koilonychia

Koilonychia is an abnormal shape of the fingernail, where the nail is thin, curved inward, and has raised ridges. This condition is often associated with iron deficiency anemia.

Leukonychia

Leukonychia is the presence of white streaks or spots on the nails, which can be caused by drugs or disease.

Pitting

Pitting is the presence of small depressions on the nail surface, sometimes accompanied by the nail becoming loose and potentially falling off. Pitting is associated with conditions like psoriasis and alopecia areata.

Ridges

Ridges are tiny, raised lines that develop across or up and down the nail, often a result of aging or trauma to the nail.

Causes of Nail Abnormalities

Nail abnormalities can be caused by a variety of factors, including:

Injury

Crushing the base of the nail or the nail bed can cause permanent deformities. Chronic picking or rubbing of the skin behind the nail can lead to median nail dystrophy, which causes a lengthwise split or ridged appearance of the thumbnails. Prolonged exposure to moisture or nail polish can also make nails peel and become brittle.

Infection

Fungal or yeast infections can cause changes in the color, texture, and shape of the nails. Bacterial infections may lead to a change in nail color or painful areas of infection under the nail or in the surrounding skin, and in severe cases, even nail loss. Viral warts can also cause changes in the shape of the nail or ingrown skin under the nail.

Diseases

Certain internal diseases and nutritional deficiencies can cause changes in the appearance of the nails. For example, iron deficiency anemia can lead to koilonychia, while heart disease, renal failure, and other conditions can result in white nail syndrome (leukonychia).

Diagnosing and Treating Nail Abnormalities

If you notice any changes in your nails, it’s important to consult a healthcare professional, such as a dermatologist or your primary care provider. They can perform a physical examination, order any necessary tests, and provide appropriate treatment options.

Diagnostic Procedures

To diagnose the underlying cause of a nail abnormality, your healthcare provider may perform the following tests:

• Visual examination of the nail
• Nail fungus culture or biopsy
• Blood tests to check for underlying conditions
• Imaging tests, such as X-rays or MRI, if there is suspected trauma or infection

Treatment Approaches

The treatment for nail abnormalities will depend on the underlying cause. Some common treatment options include:

• Antifungal medications for fungal infections
• Antibiotics for bacterial infections
• Topical creams or ointments for mild conditions
• Oral medications or supplements to address nutritional deficiencies
• Surgical removal of the nail in severe cases

Preventing Nail Abnormalities

While some nail abnormalities are unavoidable, there are steps you can take to help maintain healthy nails:

• Practice good nail hygiene, such as keeping nails trimmed and clean
• Avoid prolonged exposure to moisture or harsh chemicals
• Wear protective gloves when performing tasks that may damage the nails
• Eat a balanced diet rich in nutrients like iron and zinc
• Manage any underlying medical conditions that may affect nail health

Conclusion

Nail abnormalities can be a sign of various health conditions, ranging from infections to nutritional deficiencies. By understanding the different types of nail abnormalities and their causes, you can take proactive steps to maintain healthy nails and address any underlying issues. If you notice any changes in your nails, be sure to consult a healthcare professional for proper diagnosis and treatment.

Nail abnormalities Information | Mount Sinai

Beau lines; Fingernail abnormalities; Spoon nails; Onycholysis; Leukonychia; Koilonychia; Brittle nails

Nail abnormalities are problems with the color, shape, texture, or thickness of the fingernails or toenails.

A paronychia is an infection around the nail. Many organisms can cause a paronychia. This particular case is caused by the yeast-like organism Candida. Note the inflammation (red, swollen area) at the base of the nail and the changes that are apparent in the nail itself.

Nails may exhibit many different abnormalities. In the condition known as koilonychia, the nails are flattened and have concavities. This condition may be associated with iron deficiency.

In onycholysis the nails become loose. They may even detach from the nail bed. When not held firmly in place, the nails are rapidly damaged and debris collects beneath them.

White nail syndrome may also be called leukonychia. Leukonychia can occur with arsenic poisoning, heart disease, renal failure, pneumonia, or hypoalbuminemia.

Yellow nail syndrome is characterized by yellow nails that lack a cuticle, grow slowly, and are loose or detached (onycholysis). Yellow nail syndrome is most commonly associated with lung disorders, and with lymphedema.

Internal diseases and nutritional deficits can cause changes in the appearance of the nails.

Yellow nails are seen in the ‘yellow nail syndrome’ in which there is thickening and yellow to yellow-green discoloration of all nails. Lymphedema, especially of the ankles, and compromised respiration may be present. The nails may also be over-curved both transversely and longitudinally. Lunulae and cuticles may also be lost.

Like the skin, the fingernails are a reflection of a person’s state of health. Low levels of zinc and iron as well as thyroid problems can cause brittle nails. However, brittle nails are often a normal result of aging.

Considerations

Like the skin, the fingernails tell a lot about your health:

• Beau lines are depressions across the fingernail. These lines can occur after illness, injury to the nail, eczema around the nail, during chemotherapy for cancer, or when you do not get enough nutrition.
• Brittle nails are often a normal result of aging. They can also be due to certain diseases and conditions.
• Koilonychia is an abnormal shape of the fingernail. The nail has raised ridges and is thin and curved inward. This disorder is associated with iron deficiency anemia.
• Leukonychia is white streaks or spots on the nails often due to drugs or disease.
• Pitting is the presence of small depressions on the nail surface. Sometimes the nail is also crumbling. The nail can become loose and sometimes falls off. Pitting is associated with psoriasis and alopecia areata.
• Ridges are tiny, raised lines that develop across or up and down the nail.

Causes

Injury:

• Crushing the base of the nail or the nail bed may cause a permanent deformity.
• Chronic picking or rubbing of the skin behind the nail can cause median nail dystrophy, which gives a lengthwise split or ridged appearance of the thumbnails.
• Long-term exposure to moisture or nail polish can cause nails to peel and become brittle.

Infection:

• Fungus or yeast cause changes in the color, texture, and shape of the nails.
• Bacterial infection may cause a change in nail color or painful areas of infection under the nail or in the surrounding skin. Severe infections may cause nail loss. Paronychia is an infection around the nailfold and cuticle.
• Viral warts may cause a change in the shape of the nail or ingrown skin under the nail.
• Certain infections (especially of the heart valve) may cause red streaks in the nail bed (splinter hemorrhages).

Diseases:

• Disorders that affect the amount of oxygen in the blood (such as heart problems and lung diseases including cancer or infection) may cause clubbing.
• Kidney disease can cause a build-up of nitrogen waste products in the blood, which can damage nails.
• Liver disease can damage nails.
• Thyroid diseases such as hyperthyroidism or hypothyroidism may cause brittle nails or splitting of the nail bed from the nail plate (onycholysis).
• Severe illness or surgery may cause horizontal depressions in the nails Beau lines.
• Psoriasis may cause pitting, splitting of the nail plate from the nail bed, and chronic (long-term) destruction of the nail plate (nail dystrophy).
• Other conditions that can affect the appearance of the nails include systemic amyloidosis, malnutrition, vitamin deficiency, and lichen planus.
• Skin cancers near the nail and fingertip can distort the nail. Subungual melanoma is a potentially deadly cancer that will normally appear as a dark streak down the length of the nail.
• Hutchinson sign is a darkening of the cuticle associated with a pigmented streak and may be a sign of an aggressive melanoma.

Poisons:

• Arsenic poisoning may cause white lines and horizontal ridges.
• Silver intake can cause a blue nail.

Medicines:

• Certain antibiotics can cause lifting of the nail from the nail bed.
• Chemotherapy medicines can affect nail growth.

Normal aging affects the growth and development of the nails.

Home Care

To prevent nail problems:

• DO NOT bite, pick, or tear at your nails (in severe cases, some people may need counseling or encouragement to stop these behaviors).
• Keep hangnails clipped.
• Wear shoes that do not squeeze the toes together, and always cut toenails straight across along the top.
• To prevent brittle nails, keep the nails short and do not use nail polish. Use an emollient (skin softening) cream after washing or bathing.

Bring your own manicure tools to nail salons and DO NOT allow the manicurist to work on your cuticles.

Using the vitamin biotin in high doses (5,000 micrograms daily) and clear nail polish that contains protein can help strengthen your nails. Ask your provider about medicines that help with abnormal-appearing nails. If you have a nail infection, you may be prescribed antifungal or antibacterial drugs.

When to Contact a Medical Professional

Call your health care provider if you have:

• Blue nails
• Clubbed nails
• Distorted nails
• Horizontal ridges
• Pale nails
• White lines
• White color under the nails
• Pits in your nails
• Peeling nails
• Painful nails
• Ingrown nails

If you have splinter hemorrhages or Hutchinson sign, see the provider immediately.

What to Expect at Your Office Visit

The provider will look at your nails and ask about your symptoms. Questions may include whether you injured your nail, if your nails are constantly exposed to moisture, or whether you are always picking at your nails.

Tests that may be ordered include x-rays, blood tests, or examination of parts of the nail or the nail matrix in the laboratory.

American Academy of Dermatology website. 12 nail changes a dermatologist should examine. www.aad.org/public/everyday-care/nail-care-secrets/basics/nail-changes-dermatologist-should-examine. Accessed July 23, 2021.

Andre J, Sass U, Theunis A. Diseases of the nails. In: Calonje E, Brenn T, Lazar AJ, Billings SD, eds. McKee’s Pathology of the Skin with Clinical Correlations. 5th ed. Philadelphia, PA: Elsevier; 2020:chap 23.

Tosti A. Diseases of hair and nails. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 413.

Last reviewed on: 6/19/2021

Reviewed by: Ramin Fathi, MD, FAAD, Director, Phoenix Surgical Dermatology Group, Phoenix, AZ. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

12 nail changes a dermatologist should examine

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Subungual melanoma, cancer of the nail plate: cure, symptoms, early stage of nail cancer

Subungual melanoma, or, as some patients call it, nail melanoma, is one of the rarest forms of malignant neoplasms. It develops in the area of ​​the nail bed, at first it looks like a dark or black spot or strip, the size of which gradually increases, affecting the nail fold, the phalanx bone and its soft tissues. The tumor is prone to an aggressive course, the results of treatment to date leave much to be desired. Above is a characteristic subungual melanoma in the photo – this is what this malignant tumor looks like.

Sometimes patients also use the term “nail cancer”, but this is an incorrect name for the disease. Cancer is called malignant tumors that develop from cells of epithelial tissues: skin, mucous membranes. Melanoma is a malignant tumor that originates from melanocyte pigment cells. Thus, in this case, “nail cancer” and “cancer under the nail” are incorrect terms.

By the way, “melanoma on the nail” is also wrong to say that. The tumor is not on the nail, but under it, it’s just visible through it.

Causes of subungual melanoma

Now that we have talked about what nail melanoma is and how to properly call it, let’s figure out why it occurs.

Unlike all other malignant tumors of the skin, with subungual melanoma, excessive insolation practically does not play any role as a provoking factor in the development of the disease. This is confirmed by the fact that the neoplasm often affects the toes, which are almost constantly covered by shoes. In addition, epidemiological data suggest that subungual melanoma is 40% more common in blacks and Mongoloids.

Possible risk factors for the development of melanoma in this localization include:

• Mechanical trauma to the nail. About a third of patients with an established diagnosis noted the presence of mechanical damage to the nail phalanx in history. Most often, the toes, as well as the thumb and forefinger of the working hand, suffer from this. In addition, cosmetic and surgical interventions that are performed for various nail diseases can provoke melanoma.
• Physical injuries – frostbite and burns, use of a laser to treat or remove damaged nails.
• Exposure to chemical carcinogens on nails. About 10% of patients had prolonged contact with chemicals (occupational hazard).
• Hereditary factor. About 5-14% of melanoma patients have genetic defects, in particular, mutations in the CDKN2A, CDK4, MITF, VC1R genes.
• A large number of dysplastic nevi. In the vast majority of cases, the development of subungual melanoma occurs de novo, i.e., on unchanged tissues, but the risks of its development are higher in individuals with a large number of pigmented dysplastic nevi.
• Age over 60 years.

Predisposing risk factors for melanoma in Caucasians are fair skin, red hair, and freckles.

Symptoms of subungual melanoma

Two stages of development are characteristic of subungual melanoma: horizontal and vertical.

In the horizontal stage, pigmented subungual melanoma appears as a brown or black streak under the nail. Its color may be uneven. In a third of patients, there is an expansion of pigmentation with involvement in the process of the free edge of the nail, nail fold and skin.

For pigmentless melanoma (which, by the way, occurs in 30% of cases), such signs are not typical, and the disease goes unnoticed for a long time. The first symptoms develop at the vertical stage, when the tumor begins to invasively grow into the surrounding tissues. At this time, the deformation of the nail occurs. The nail plate becomes dull, loses its natural shine. Its thickness becomes thinner, the nail becomes brittle, exfoliates and breaks easily. As the tumor increases in size, the nail cracks and a bumpy surface is revealed underneath. In the case of pigmentary melanoma, it will be brown or black with patches of more pigmented areas. With mechanical contact, this surface bleeds easily.

Does subungual melanoma hurt? In the early stages, the disease is not accompanied by any discomfort. In some cases, subungual melanoma is accompanied by a burning sensation, itching, or fullness. As the pathology progresses, the tumor involves new tissues in the process, spreading to the soft tissues of the fingers, feet or hands. The pain syndrome increases and the person cannot fully use the affected limb.

Systemic symptoms of melanoma include general weakness, weight loss, persistent fever. When metastasizing, symptoms from the affected organs join. The rate of progression of the disease is different for each patient. In some cases, several years pass, and in others, metastases are detected as early as a year after the primary occurrence of melanoma.

Subungual melanoma: when to worry? You need to see a doctor for any suspicious changes in the nail. Even if it turns out that they are not caused by a malignant tumor, but by another disease, in any case, it is better to start treatment in a timely manner.

In addition to melanoma, there is such a condition as cancer of the nail plate, in the medical language – onychomatricoma. She herself is hidden under the skin, but leads to changes in the nail.

Classification

• 0 stage, or melanoma in situ – the initial stage of melanoma of the nail. There is dysplasia or non-invasive malignant cell involvement.
• stage 1 – the thickness of melanoma is not more than 1 mm, or up to 2 mm, but without ulceration of the surface.
• Stage 2 melanoma is set if the thickness of the ulcerated tumor is more than 2 mm or more than 4 mm in the absence of ulceration of its surface.
• stage 3 – any thickness of melanoma in the presence of metastases in regional lymph nodes.
• stage 4 – there are metastases in the internal organs.

Among the clinical and morphological types of tumors in the area of ​​the nail bed, as well as on the fingers, in the interdigital spaces, on the palms and soles, acral nail melanoma is often found. It is characterized by some specific features.

Diagnostic methods

Subungual melanoma refers to tumors of external localization, however, timely diagnosis can be difficult due to the similarity of the clinical picture with nevi, subungual hematomas and hemangiomas. To differentiate the nature of the neoplasm, special dermatological research methods are used:

• Dermatoscopy is a visual assessment of pathologically altered tissues using multiple magnification.
• Epiluminescence microscopy — dermatoscopic examination of pathologically altered tissues in an immersion medium. This technique allows with a high degree of probability to differentiate a benign neoplasm from a malignant one.

If there are changes in the nail plate, a cytological examination of impression smears can be performed. The final diagnosis is made after the histological conclusion. In the case of melanoma, it is strongly not recommended to take a biopsy so as not to provoke metastasis. Therefore, the study is carried out after a radical surgical operation.

If subungual melanoma cannot be ruled out within two months after the patient’s visit, a marginal resection of the nail plate with matrixectomy is performed, followed by a histological examination of the obtained material. When the diagnosis is confirmed, radical surgery is indicated.

To determine the stage of the disease, radiation research methods (ultrasound, CT or MRI) are used, which allow determining the presence of local and distant metastases.

Differential diagnosis

With subungual melanoma, it is often necessary to carry out differential diagnosis with such pathologies as:

• panaritium – purulent inflammation of the tissues of the finger;
• warts – benign neoplasms caused by human papillomaviruses;
• onychomycosis – fungal infection of the nails;
• nevus – a benign neoplasm of pigment cells;
• subepidermal hematoma;
• subungual hematoma;
• hemangioma is a benign neoplasm of dilated blood vessels.

Treatment of subungual melanoma

The main point in the treatment of subungual melanoma is radical surgery. Its scope is still a matter of controversy. Previously, it was believed that the higher the resection, the lower the likelihood of recurrence and metastases. Therefore, disarticulation of the entire finger was performed. However, studies have shown no statistically significant difference in survival in patients with subungual melanomas who underwent disarticulation compared with those who underwent resection at the level of the middle phalanx of the finger. Therefore, the last option of intervention is currently accepted. This does not worsen the patient’s prognosis and preserves the quality of his life as much as possible.

Radiation therapy

Radiation therapy in the treatment of subungual melanoma is used to irradiate tumor recurrence in the area of ​​the postoperative scar. The second application is the impact on the area of ​​primary lymph nodes to prevent the spread of lymphogenous metastases.

Chemotherapy

Chemotherapy for subungual melanoma can be used in two ways – systemic and regional. At the same time, different protocols may imply adjuvant and neoadjuvant regimens.

Neoadjuvant chemotherapy involves treatment before surgery. This allows you to reduce the size of the tumor and create conditions for its surgical removal.

Adjuvant regimens are prescribed in the postoperative period, and their goal is to destroy the remaining malignant cells, reduce the risk of recurrence and metastasis. As part of chemotherapy, regimens containing dacarbazine, lomustine, tamoxifen, etc. are used. Unfortunately, the effect can only be achieved in 15-20% of patients.

Other treatments

Great promise in the treatment of subungual melanoma lies with immunotherapy and gene therapy. For example, it has been shown that the administration of interferon, interleukin-2, or granulocyte-macrophage colony-stimulating growth factor has a positive effect on the treatment prognosis – overall survival increases, the relapse-free period is extended.

Suppression of p53 and p16INK4a is proposed as a gene therapy for melanomas. These genes activate pathological signaling pathways, through which the cell acquires the ability to divide uncontrollably and invasively grow into underlying tissues.

Complications

Subungual melanoma is characterized by an aggressive course. This is one of the most aggressive forms of this disease. Radical surgery for an invasive tumor does not guarantee a complete cure and prevention of recurrence or the development of metastases. Most often, metastases are found in the lungs and liver, and in terms of the degree of malignancy, they surpass the primary tumor. As the process develops, general complications characteristic of malignant neoplasms join: weakness, anemia, cachexia, etc.

It must be taken into account that the surgical removal of the primary focus of melanoma leads to a partial loss of function of the affected limb. During surgery, a visible defect is formed on the arm, which is almost impossible to hide from others, plus the functionality of the hand is impaired.

In some cases, surgery on the foot requires resection of the metatarsus. This greatly reduces the support of the operated leg and creates an additional load on other parts of the musculoskeletal system, leading to the development of arthrosis, myositis, muscle spasms and other disorders.

Prevention of subungual melanoma

Prevention of the development of subungual melanoma involves the following activities:

• Protection of limbs from mechanical and physical injuries.
• Protection against chemical agents.
• Genetic testing of individuals at high risk of familial melanoma.
• Observation and timely removal of nevi.

Prognosis for subungual melanoma

The prognosis for subungual melanoma depends on many factors, the key factors being Breslow tumor thickness, level of invasion, and presence of distant metastases. The 5-year life expectancy in the absence of metastases is about 60%, the median survival is 50-55 months. In the presence of metastases, the median survival ranges from 7-8 months. At the same time, radical surgery does not affect life expectancy.

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Paronychia is a purulent inflammation of the periungual fold and tissues at the base and sides of the nail. The main reason is infection under the skin as a result of trauma, prolonged exposure to chemicals, or non-compliance with personal hygiene. Also, complications of certain skin, infectious or endocrinological diseases can become the cause of paronychia.

There are several forms of paronychia:

• Tourniolus is the most common form of the disease, characterized by gradually increasing suppuration and an increase in painful symptoms. The form is characteristic of infectious paronychia caused by fungi of the genus Candida or streptococcal infection.
• Erosive and ulcerative forms – develop with syphilis, pemphigus, Duhring’s disease. They are characterized by the appearance of vesicles and ulcers on the skin around the nail, from which “ichor” or pus periodically seeps out. The pathological process often passes to the nail.
• Chronic paronychia is a long-term inflammatory process in which the cuticle may be completely absent, and the nail plate is often thickened or deformed. Chronic paronychia may result from prolonged exposure to chemicals.

Description and symptoms of paronychia

Paronychia begins with swelling and redness of the periungual fold. There is pain and a local increase in temperature. After a while, an abscess and accumulation of pus form.

The further course of the disease leads to spontaneous outpouring of pus from under the nail fold or under the nail plate. In the second case, the nail acquires a yellowish-green color. In some cases, the periungual roller is covered with whitish scales or crusts, ulcers or vesicles.

If left untreated, the disease becomes chronic, in which the nail thickens and deforms. There is a risk of complete loss of the nail plate. Also, the lack of treatment can be fraught with complications such as phlegmon, abscess, tissue necrosis, infection of the tendons, sepsis.

Diagnosis and treatment of paronychia

Only a surgeon can diagnose the disease. In most cases, a simple examination is enough to make a diagnosis. But in order to determine the cause of the disease, it may be necessary to conduct a general blood test, a blood test for sugar and a Wasserman reaction. To exclude a fungal infection, a biopsy of the nail plate is necessary (if the pathological process has affected not only the periungual tissues, but also the nail itself).

Because different causes and forms of paronychia require different treatments, it is recommended that you see a doctor as soon as the first symptoms appear.