ABC OF : NAIL DISORDERS. ( I ). MAY BE USEFUL. ANONYCHIA is the absence of nails, an anomaly, which may be the result of a congenital ectodermal defect, ichthyosis, severe infection, severe allergic contact dermatitis, self-inflicted trauma, Raynaud phenomenon, lichen planus, epidermolysis bullosa, or severe exfoliative diseases....... PSORIASIS can also affect the fingernails and toenails, leading to thick fingernails with pitting, ridges in the nails, nail lifting away from the nail bed, and irregular contour of the nail....... LICHEN PLANUS of the nails can cause brittle or split nails, and the affected nails may have ridges running lengthwise....... FUNGAL nail infections are common infections of the fingernails or toenails that can cause the nail to become discolored, thick, and more likely to crack and break. Infections are more common in toenails than fingernails.....by some dermatophytes, Candida (Monilia) species, etc....... The technical name for a fungal nail infection is “ONYCHOMYCOSIS.”....... SPOON-SHAPED or spooning fingernails refers to a concavity in the fingernail itself, resulting in a depression in the nail that gives an appearance of a spoon shape to the entire nail. This growth disturbance in the nail is known as KOILONYCHIA....... In particular, koilonychias is associated with IRON DEFICIENCY. Fingernails are made by living skin cells....... So a skin condition such as eczema may lead to fingernail ridges. Skin dryness can also cause these ridges. If the body is low in protein, calcium, zinc.......or vitamin A, a deficiency can sometimes be revealed by ridges in the fingernails. ** HORIZONTAL RIDGES run from side to side on nails and are often referred to as BEAU'S LINES may be a sign of previous injury, underlying health conditions, or in rare cases, arsenic poisoning....... Horizontal ridges can be caused by trauma to the nail and may be deep or discolored. The can also indicate malnutrition, psoriasis or a thyroid problem....... ** VERTICAL RIDGES are usually harmless and a consequence of ageing.......nail injury, or trauma, or underlying medical conditions....... The ECTODERMAL DYSPLASIAS (EDs) are genetic disorders affecting the development or function of the teeth, hair, nails and sweat glands....... ** ED is not a single disorder, but a group of closely related conditions of which more than 150 different syndromes have been identified....... Nail CLUBBING, also known as digital clubbing, is a deformity of the finger or toe nails associated with a number of diseases, mostly of the heart and lungs. ... Hippocrates was probably the first to document clubbing as a sign of disease, and the phenomenon is therefore occasionally called "Hippocratic fingers"..... ** Lung cancer is the most common cause of clubbing. Clubbing often occurs in heart and lung diseases that reduce the amount of oxygen in the blood. ... Heart defects that are present at birth (congenital) Chronic lung infections that occur in people with bronchiectasis, cystic fibrosis, or lung abscess....... While the NAIL BITING and picking seems to be such a common problem, the psychological and medical research does not agree on the exact motivation for the action. However, it suggests that nail biting can be the result of STRESS, VARIOUS MEDICAL DISORDERS, LEARNED BEHAVIORS, OR JUST PLAIN HABIT....... SPLINTER HEMORRHAGES : They run in the direction of nail growth. They are named splinter hemorrhages because they look like a splinter under the fingernail. The hemorrhages may be caused by tiny clots that damage the small capillaries under the nails. Splinter hemorrhages can occur with infection of the heart valves (endocarditis)....... YELLOW TOENAILS in an infection by a fungus that attacks the nails..... or, in some cases, they may be a sign of skin cancer. The fungal infection is caused most often by dermatophytes, which eat keratin to grow....... One of the MOST COMMON CAUSES of YELLOW NAILS is a FUNGAL INFECTION. As the infection worsens, the nail bed may retract, and nails may thicken and crumble. In rare cases, yellow nails can indicate a more serious condition such as SEVERE THYROID DISEASE, LUNG DISEASE, DIABETES or PSORIASIS....... WHILE NAILS ( LEUKONYCHIA ) : CAUSES : Iron deficiency anemia. Cirrhosis of liver. Kidney disease. Heart failure. Diabetes. Problems with the digestion of proteins. An excessive loss of proteins in the intestines. zinc deficiency........etc....... RED NAILS :- CAUSES : LUPUS patients get quirky, angular blood vessels in their nail folds. PSORIASIS starts in the nails up to 10 percent of the time and CAUSES SPLITTING and PITTING of the nail bed. HEART DISEASE can turn the nail beds red....... ** If the NAIL BED is RED, it could be caused by a high content of fatty acids and cholesterol, due to an excess of dairy products, sugar and salt in the diet. This can lead to an underactive liver and blocked arteries....... To keep the system healthy by replacing refined foods with wholegrain rice and bread, and flush out the system with plenty of fresh vegetables and at least five glasses of water a day....... HALF PINK and HALF WHITE nails can be a sign of kidney disease....... BRITTLE NAILS :- CAUSES : AGING. CHEMICAL/TOXIN EXPOSURE. LONG-TERM USE OF NAIL POLISH AND POLISH REMOVE. LOW HUMIDITY ENVIRONMENT. MALNUTRITION. NAIL-PATELLA SYNDROME. PROLONGED EXPOSURE TO WATER. TRAUMA. ** B complex vitamins (especially biotin), calcium, and zinc have all been implicated. There are other medical conditions which can cause brittle nails such as ANEMIA (low blood count), THYROID DISORDERS, and skin disorders such as LICHEN PLANUS and PSORIASIS. ** ONYCHOSCHIZIA includes splitting, brittle, soft or thin nails. Onychoschizia is MORE COMMON IN WOMEN. Only VERY RARELY are INTERNAL DISEASE or VITAMIN DEFICIENCIES the reason (IRON DEFICIENCY is the MOST COMMON).......

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LUNG CANCER IS THE MOST COMMON CAUSE OF CLUBBING. * CLUBBING has been described to occur in different stage....... GRADE 1 to GRADE 5.......Although DIFFERENT GRADING of clubbing has been described, it has NO CLINICAL SIGNIFICANCE.......This whole process ( Great 1 to Get 5 ) usually takes years but in certain conditions, clubbing may develop sub-acutely (e.g. lung abscess, empyema thorasis)....... Clubbing may be associated with various clinical conditions. HOWEVER, lung diseases are most commonly associated with clubbing and NEOPLASTIC LUNG DISEASE IS THE MOST COMMON PULMONARY CAUSE OF CLUBBING. OTHER LUNG DISEASES that can be associated with clubbing are bronchiectasis, lung abscess, interstitial lung disease, fibrous pleural tumors, mesothelioma, etc....... Other diseases are : CARDIAC CONDITIONS (namely, CYANOTIC HEART DISEASES, INFECTIVE ENDOCARDITIS) and GASTROINTESTINAL diseases namely, INFLAMMATORY BOWEL DISEASE, COELIAC DISEASE, CIRRHOSIS mostly primary biliary cirrhosis). There are also cases of CONGENITAL and IDIOPATHIC clubbing, and PSEUDO-CLUBBING..... In adults, MALIGNANT NEOPLASM OF THE LUNG is the predominant pulmonary cause of clubbing, CONTRIBUTING TO NEARLY 90% OF CASES. AMONG the DIFFERENT types of THORACIC MALIGNANCY, LUNG CANCER IS RESPONSIBLE FOR 80% CASES OF CLUBBING, whereas pleural tumors and other intrathoracic and mediastinal growth contribute to 10% and 5% cases, respectively. On the other hand, the prevalence of clubbing in lung cancer patient ranges from 5% to 15%. Clubbing in lung cancer is a paraneoplastic manifestation and is also the most common paraneoplastic syndrome in lung cancer patients. A MAJORITY of clubbing in lung cancer patient involves NON-SMALL CELL VARIETY. Clubbing is relatively uncommon in small cell lung carcinoma because of its aggressive course and poor prognosis, thereby leading to early death. HOWEVER, contrary to this classical view, Findik and Baughman et al.'s series reported similar incidence of clubbing in both SCLC and NSCLC patients. Most studies did notice a MALE PREDOMINANCE of clubbing in lung cancer patients except Sridhar et al. who found a female predominance of clubbing in lung cancer patients. The megakaryocyte/platelet hypothesis appears quite reliable in explaining digital clubbing in lung cancer patients. Hirakata et al. also reported increased serum transforming growth factor (TGF ß1) level in primary lung cancer patients with clubbing. Therefore, large megakaryocyte or platelet clumps may release TGF ß1 level locally which may increase local accumulation of extra cellular matrix protein. There are few case reports of digital clubbing occurrence in malignant mesothelioma, pleural fibroma, and metastatic osteogenic sarcoma. McGavin et al. noticed finger clubbing based on abnormal fluctuation of nail bed in 30% of the MESOTHELIOMA and 14% of benign ASBESTOS PLEURAL DISEASE, respectively. The incidence of clubbing in malignant pleural mesothelioma is high enough to be included in the list of digital clubbing. Solitary fibrous tumor of pleura is less common than malignant mesothelioma. Moreover, they are MESENCHYMAL in origin unlike MESOTHELIAL origin of mesothelioma. They often develop characteristic paraneoplastic syndrome of clubbing, HOA, and hypoglycemia, not typically seen with mesothelioma. Inflammatory pseudo-tumor is a rare benign lung tumor of uncertain etiology, occurring more commonly in younger patients. Vandemergel et al. reported the first association of inflammatory pseudo tumor with digital clubbing in an adult patient. PULMONARY METASTASES from extrathoracic neoplasms are RARE CAUSE OF CLUBBING and HPOA. Most of the reported cases have been SARCOMAS, mainly of BONE and soft TISSUES; among the rest are tumors of the nasopharynx and uterus and cervix and RENAL CELL CARCINOMA. Renal cell carcinoma has been USUALLY ASSOCIATED CLUBBING in the presence of pulmonary metastases. However, in the Vandemergel et al. series renal cell carcinoma patient with digital clubbing did not have evidence of lung metastasis. HODGKIN'S LYMPHOMA is rarely associated with digital clubbing. Characteristically, clubbing is mainly seen in the presence of intrathoracic involvement and in children and adolescents. In patients of Hodgkin's lymphoma, the presence of clubbing requires searching for an underlying intrathoracic neoplasm. INTERSTITIAL LUNG DISEASE is frequently associated with digital clubbing. AMONG DIFFERENT ILDs, digital CLUBBING is MOST COMMONLY NOTED IN IDIOPATHIC PULMONARY FIBROSIS (IPF), which is also the most common pulmonary cause of digital clubbing in developed country. Kanematsu et al. reported clubbing in 67% of the 55 patients of idiopathic pulmonary fibrosis. Ryu et al. from Mayo clinic reported digital clubbing in 45% of IPF patients younger than 50 years. Rarely, patients may develop features of HOA associated with severe pain in the distal extremities. CLUBBING RARELY occurs IN SARCOIDOSIS and is usually seen in advanced fibrotic stage. ASBESTOSIS is another ILD where clubbing is commonly seen. Coutts et al. noted finger CLUBBING IN 43% of ASBESTOSIS PATIENTS and is usually seen in patients with more severe form of disease. Digital clubbing, complicating INFLAMMATORY BOWEL DISEASE has been frequently reported in the Western country. However, its association with secondary HOA has been very rarely found. Digital clubbing is more commonly noted in CROHN'S DISEASE than in ULCERATIVE COLITIS . Kittis et al. reported digital clubbing incidence of 38% and 15% in patients with Crohn's disease and ulcerative colitis, respectively . ** Megakaryocytes or platelet or their derivatives may play a role in the pathogenesis of clubbing in inflammatory bowel disease. Collins et al. have detected increased circulating platelets aggregates as well as an increase number of platelets in patients with Crohn's disease. Normally, P-SELECTIN (a surface marker of platelet activation) expression is greater in finger tip capillary blood than in venous blood; this difference is further increased in Crohn's disease. So platelets are more susceptible to activation in the micro-circulation in Crohn's disease which could result in increased release of PDGF. Finger clubbing is more significantly associated with active disease than inactive disease in patients with IBD. Patients with Crohn's disease have shown regression of clubbing after resection of macroscopic disease. There is also a possibility that mucosal inflammatory changes and fibrosis in the gut may act as focal stimuli for vagus nerve and possibly other autonomic nerve, acting as the afferent arc of a finger clubbing reflex. BEHCETS DISEASE and HEPATO-PULMONARY SYNDROME are RARE CAUSES of clubbing. VASCULITIS of digital vasculature by impairing endothelial functions promote platelet aggregation and may cause clubbing. Digital clubbing is mainly reported in BILIARY CIRRHOSIS but has also been described in other liver diseases, such as PORTAL CIRRHOSIS, SECONDARY HEPATIC AMYLOIDOSIS, ALCOHOLIC CIRRHOSIS, and BILIARY ATRESIA. CLUBBING IN ENDOCRINE DISEASE :- Clubbing has been reported in few endocrine conditions: THYROID ACROPACHY, HYPERPARATHYROIDISM. HUMAN IMMUNODEFICIENCY VIRUS AND CLUBBING :- Human immunodeficiency virus (HIV) and clubbing is an interesting topic but STUDIES ARE WEAK. ONLY FEW CASE REPORTS are there LINKING HIV infection AND CLUBBING. However, direct linking of HIV to clubbing is STILL a matter of CONTROVERSY. In an observational study, Dever et al. reported 36% incidence of clubbing in HIV infected outpatients. Patients with digital clubbing are slightly younger in age and had history of longer duration of HIV infection. Clubbing in HIV-infected patients has generally been attributed to CONCOMITANT PULMONARY INFECTION. Ddungu et al. assert that clubbing is MORE often present IN PATIENTS WITH PRIOR tuberculosis (TB). CLUBBING AND CARDIOVASCULAR DISEASE :- INFECTIVE ENDOCARDITIS usually causes a milder form of clubbing, whereas in CONGENITAL CYANOTIC HEART DISEASE, gross, drumstick appearance may be seen. Although digital clubbing is common in patients with cyanotic congenital heart disease (CCHD), HOA is rarely reported in this condition. However, one Mexican study reported a higher frequency of HOA of 31% in congenital cyanotic heart disease. CLUBBING AND PULMONARY TUBERCULOSIS :- ALTHOUGH TB has NOT been REPORTED AS A CAUSE OF CLUBBING IN MAJOR TEXTBOOKS OF MEDICINE, there are SEVERAL CASE REPORTS of its occurrence in TB patients. Studies from endemic areas of TB have shown a 30% frequency of clubbing amongst smear-positive TB patients. ONE INDIAN STUDY also reported a very high frequency of digital clubbing (82%). MacFarlane et al. in an earlier study in Nigeria reported associations of clubbing with severity of disease, cavitary TB, and hypoalbuminemia, indicative of chronic disease. Henry et al. could not find significant association between clubbing and duration of illness, frequency of cavitation, early versus late HIV disease, and hypoalbuminemia, but it was more common among patients with a lower Karnofsky performance scale score or with prior TB......... Dear@Dr. Asv Prasad in the context of nail clubbing, I have mentioned " Lung cancer is the most common cause of clubbing often occurs in heart and lung diseases..................or lung abscess......." Please go through this, where different studies are cited, with different percentage of clubbing in different disease....... etc etc. Thanking you. Regards, Puranjoy Saha.

Dr Saha Sir, U literally 'clubbed my head' with statestics. You may perhaps agree that the literature produced says that , 'Of the pulmonary causes, ca long is the commonest cause , Which is not same as ' the commonest cause '. The literature quotes the relative incidence , say in all pulmonary cases etc studied . Here also as u have rightly pointed out, there is discrepancy among studies. One NCBI quoted study puts - ' idiopathic pulmonary fibrosis ' at an incidence of 85% where as ca lung is given 29 %. U know that the statestics vary from study to study and within the same study due to ' sample size'- which has inverse relationship with incidence !. 'Sample bias' is also there. High incidence of asbestosis is seen in population effected by that pnumoconiosis where as outside the figures might not be true. Ethnic factors also play a role. In one study nearly 1/3 of 'UGANDAN ' pts studied were reported to have clubbing. Westren books don't consider P.TB as a cause as the incidence of PT is very less there. I was embarrassed when students were indicted in exms for citing PT as a cause , taking a leaf from the clinical medicine book written by me . We live with TB yet it is not accepted here what is accepted in UGANDA. ! The real commenest incidence of a cause is found when a large scale study incuding all possible causes is conducted. However my caution was that examiners perhaps don't like the ans as Ca lung being the commonest cause of clubbing. " Afteral we have to give ans to their likings if not their 'whims and fancies'. I will end this discussion quoting my real time experience in one exm. When one student quoted from my book, pulmonary AV fistula as a cause of clubbing, the examiner exhibited ' tantrum fits'.. Parodoxically it did not sooth the situation when , I immediately opened the internet on my mobile and furnished the ' required ' evidence ! Besides students, there are innocent Curofians who might jump to the conclusion on seeing a case of cubbing as ca lung , as it is cited as ' the commonest cause. " Anything even wrong, if done for a right cause should be exonerated !- and it is precisely what I request from you Sir. Nevertheless , though none would dare to ' sit in judgement' as to the relative merits of the arguments, it is hoped that the discussion would serve a 'good feast' to those with " literary bent of mind ". Regards Sir, conceeding that al lthis ' hocus- pocus' is just for discussion sake !

@ Dr Puranjay Saha Sir , microbiologist.
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Comprehence. Thanks for sharing Sir. One correction about clubbing. That it is most common in lung Cancer. This may sènd wrong signals. Grade 4 or hypertrophic pulmonary osteoarthropathy is the characteristic feature of ca. Lung.

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Nice and informative sir for day to day practice.

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Really Nice and informative post sir

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Very nine and informative post sir.

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Nice and helpful post sir

Informative ...

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Nice update

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very nice

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