In the previous parts we have in detail considered features and bases of the differential diagnosis of changes of a form and the sizes of nails. In two parts of the real work main types of change of colouring of a nail plate and the surrounding fabrics are presented, quite often helping not only it is correct to establish the diagnosis, but in certain cases, for example at timely detection of a polosovidny melanonikhiya, - in due time to distinguish and begin onkopatologiya treatment, to keep life of the patient.
Change of colour of nails, part I
White nails (leykonikhiya)
Leykonikhiyey is called a resistant pobeleniye of nails. It is subdivided on total (when involving ? 80 areas of a nail) and partial. The most frequent reason of a total leykonikhiya is the gipoalbuminemiya. Also is one of characteristic signs of a POEMS-syndrome (Polyneuropathy, Organomegaly, poly-Endocrinopathy, Myeloma proteins, Skin lesions). Identification of this symptom, especially at patients with suspicion on development of a limfoproliferativny disease, demands carrying out the corresponding differential diagnosis (see tab. 1).
Differential diagnosis of a leykonikhiya
- Lines Mey (fig. 1) - change a site with nail growth
- Poisoning with arsenic
- Poisoning WITH
- Hodzhkin's illness
- Stagnant warm insufficiency
2. The Muehrcke lines (fig. 2) - do not change the site with nail growth
3. Terri's Half-and-Half lines (40-80 % of the area of a nail) (fig. 3)
Leykonikhiya total (? 80 areas of a nail) (fig. 4)
- The idiopathic
- Hereditary (FLOTCH, Gorlin-Bushkell-Jensen-syndrome, etc.)
- Gipoalbuminemiya (< 20 г/л) - исчезает при нормализации уровня альбумина
- Stagnant warm insufficiency
- Limfoproliferativnye of a disease (POEMS, illness of easy chains of antibodies, etc.)
Drawing of 1 Line Mey
Muehrcke Line drawing 2
Drawing 3 of the Half-and-Half Line of Terri
Drawing 4 Leykonikhys total
The differential diagnosis of yellow colouring of a nail and/or surrounding fabrics is presented in table 2.
- Not medical reasons: smoking, frequent polishing of nails
- Hereditary reasons: syndrome of a yellow nail
- System psoriasis
- The diseases, being accompanied chronic the limfostazy
- Gipertireoidnye of a condition
- Reynaud's syndrome
- Ochagovy (gnezdny) allopetsiya
- Medicines: тетрациклин, акрихин
- Thermal burn
- Neuropathies of median and/or ulnarny nerves
Syndrome of a yellow nail (fig. 5) - a rare hereditary disease of an unknown aetiology. For the first time P.Samman in 1964 is described. Meets extremely seldom: now about 100 cases are described. In a basis патогенеза defect of development of lymphatic system and, probably, peripheral blood circulation lies. Nails of the top extremities are surprised a little more often than nails of feet.
Drawing 5 Syndrome of a yellow nail
In the classical description it is shown by a triad of symptoms:
- Emergence by yellow colouring of nails, delay of their growth, and also thickening, fragility, transparency loss, lunochka disappearance.
- Lymphatic hypostasis (is more often than the bottom extremities). Can precede change of colouring of nails.
- Pleural exudate (as option: the pathology of bronkholegochny system described by some authors).
In clinical practice often to have to differentiate an onikhodistrofiya with defeat of nails within psoriasis. Taking into account lack of clinical signs strictly specific to psoriasis carrying out histologic research is most proved. In lack of possibility of its carrying out it is possible to be guided by a number of signs with bigger degree of probability allowing to make the correct diagnosis: (tab. 3)
The main signs, characteristic for psoriasis:
- Onikhodistrofiya as "thimble" also called «Geller's symptom», «Rozenau's symptom» - dot deepenings on a nail surface (fig. 10). Originally arise on a proksimalny part of a nail plate. Can be both individual, and multiple. More expressed defeat is accompanied by education on a surface of a nail of multiple longitudinal crests иборозд. Often are harbingers of emergence of arthritises.
- Onikholizis - feature is frequent detection of a narrow reddish or yellowish strip in the distalny part of a nail bed which is appearing through through a nail plate.
- Eritematozo-pyatnistye and papulezny forms - the small and larger hemorrhagic spots which are gradually getting желтоватыйили a yellowish-brown shade (a symptom podnogtevy purples, or a symptom of «an oil spot» Gottrona).
- Popov's symptom - a hypertrophy эпонихиума, reminding psoriatichesky папулу.
- Symptom of «sandy waves» - a longitudinal and cross-section ischerchennost of a nail in the form of wavy lines. There can be a long time, without leading to nail destruction.
Onikhodistrofy's drawing 10 as "thimble"
Black nails (melanonikhiya)
The Polosovidny melanonikhiya (PM) (fig. 6) is quite frequent find among Spanish, the Afro-American population. Frequency of occurrence in population according to different authors varies within 0,7-3,5 %; increases with age: 20-29 years - 0,6 %; ?50 years - 1,7 %. Among the European population of PM in norm practically does not meet. The main reasons for emergence of PM are presented in table 4.
Reasons of emergence of PM
- Podnogtevy hematoma (к.п. runners)
- The hereditary
- in situ melanoma; central nevus; melanotsitarny макулы
- Infection (some types аспергиллеза, скопуляриопсиса, sinegnoyny stick).
- Drugs: gold preparations; cyt
ostatics (миноциклин, циклофосфан); мепакрин, фенолфталеин;
- Intoxication arsenic, fluorine (флюороз)
- Addison's illness
- Deficiency В12
- Ionising radiation
- Peutz-Jegers syndrome
- Laugier-Hunziker-Braun syndrome
Drawing 6 of Polosovidnaya melanonikhiya
At PM identification the greatest vigilance should be concerning a melanoma, the second for frequency, after a ploskokletochny carcinoma, a malignant new growth of a fabric of a nail the five years' survival rate at which varies within 18-68,5 %. Even at normal results of primary biopsiyny research, the patient should remain under fixed supervision of the dermatologist, the oncologist. It should be noted that Hutchinson’а symptom (fig. 7) not always is 100 %-m confirmation of existence of a melanoma that once again dictates need of carrying out morphological verification.
Drawing 7 Hutchinson’а Symptom
The factors increasing probability of existence of a melanoma at patients with PM (tab. 5)
- Light skin colour
- Sharp change of colour and/or pigmentation form
- Involvement of one finger (especially big, index)
- Hutchinson’а symptom (pigmentation distribution from a nail bed, the roller or a nail plate on a proksimalny cuticle and proksimalny, lateral nail folds)
- Advanced age
- Width of the line of ?3 mm
- Family anamnesis.
About what can tell nails>>>
Nails, part I: Changes of a form and sizes>>>
Nails, part II: Dystrophic changes>>>
Nails, part IV: Dark blue, red, brown nails>>>