Nails—They Mean More Than You Think!—Part 1 (Rehm)

MedicalC ontinuingEducation Continuing Medical Education

Objectives and Goals

1) To understand the importance of nail pathology in clinical practice.

2) To appreciate the diagnostic opportunities available through a good history and physical in a patient with nail disease. Nails—They Mean 3) To be able to create a differential diagnosis through careful investigation of the nail pathology. More Than You 4) To understand the signif- icance of proper diagnosis and treatment of nail disorders. 125 Think!—Part 1 5) To identify medical conditions and co-morbidities that ac- company different nail conditions.

6) To define the parameters Take a good history. of the decision-making process You’ll be amazed at what you find out! of treating diseased toenails in clinical practice.

7) To empower the podiatric physician to consider the whole By Kenneth B. Rehm, DPM patient when developing a treatment plan for diseased toenails.

Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Con- tinuing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $25.00 per topic) or 2) per year, for the special rate of $195 (you save $55). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. You can also take this and other exams on the Internet at www.podiatrym.com/cme. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned credits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 134. Other than those entities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected]. Following this article, an answer sheet and full set of instructions are provided (pg. 134).—Editor

e used to call it cipher used to indicate the routine “Though the world may be a C&C, literally mean- trimming of toenails, corns, and cal- jungle, not all abnormal nails are ing cutting corns luses—treatments considered to be fungal”—Anonymous and calluses. In the most mundane of all podiatric Wreality, it was a Continued on page 126 www.podiatrym.com MARCH 2015 | PODIATRY MANAGEMENT CME Continuing

Medical EducationNails (from page 125) as world-class hospital and surgical and financially rewarding, as well privileges. Yet the core of what orig- as providing a great service to your services, held in low esteem by inally was podiatry—i.e., the routine patients. podiatrists and other medical pro- prophylactic care of corns, calluses, Analogous to the pattern and fessionals alike, even though they and diseased toenails—has remained types of callus formations that are markers for biomechanical abnormal- ities, diseased toenail patterns can be a marker for systemic and topical dis- Psoriatic nail disease eases, and now raise the profession- often mimics onychomycosis. al and commercial status of treating those long thick discolored dystrophic and fungal toenails. Toenail diseases are now being treated by many proved to be invaluable services. the least prestigious of all podiat- different medical specialties, particu- Podiatric physicians and surgeons ric treatments provided. This is, of larly with the continuing popularity have since gained high status in the course, in spite of this type of routine of oral and topical medications, and world of medicine through outstand- care being one of the top reasons now with the advent of laser therapy ing education and training as well why patients go to podiatrists. Some and the widespread advertisements podiatrists actually of such. refuse to do rou- We as podiatric physicians and tine care on their surgeons, however, are the best patients and dele- at nail care. Therefore, we should gate that to lower take pride and ownership of this 126 level practitioners, special area of practice. As such, a or refer this kind of more formal approach toward the work to podiatric diseased toenail is warranted. A pro- physicians and sur- tocol would do justice to the diag- geons who relish nosis and treatment of diseased toe- that type of work. nails. The remainder of this article Hold on to expands on the idea of developing

Figure 1: Gnawed nails due to chronic nail biting The diagnostic possibilities are even expanded by the geneticist and pediatrician who look at nail pathology as a sign of inherited disease.

that ego, Docs! a protocol for treatment of diseased The subject of toenails. diseased toenails Because of the intricacy in- has never been so volved in the diagnosis of nail pa- Figure 2: Allergic and chemical contact injury to toes popular among thology, complaints, problems, and both patients and disease, this set of issues should be the medical pro- approached in the same medically fession, what with professional way as any medical or television and print podiatric problem. A history and ads persistently af- physical examination focused at re- firming the need vealing the cause of the nail pathol- for treating these ogy must be performed and a diag- conditions. The nosis made before any treatment is need has never rendered. been greater and Very often, toenails are some- can be academical- times too-quickly deemed onycho- Figure 3: Fungal infection of the toenails ly, professionally, Continued on page 127

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Nails (from page 126) The diagnostic possibilities are Initial History even expanded by the geneticist and Good medical practice dic- mycotic when, in fact, a myriad of pediatrician who look at nail pathol- tates that a complete history be pathological conditions can exist. ogy as a sign of inherited disease performed before proceeding with Making the diagnosis of specific nail and an aid in the assessment of syn- the examination. The initial history pathology is often formidable. The dromes seen at birth. Nail disease for a patient with a chief complaint differential diagnosis includes, but is is often traumatic or subject to the of nail-related disease, therefore, not limited to, nail signs of systemic effects of faulty biomechanics and should comprise sophisticated inqui- disease, trauma, infection, endocrine can cause painful and infected digits ry for the purpose of discovering the appropriate historical background that would reveal any of the seven An initial diagnostic work-up basic causes of nail disease: 1) Injuries of toenail disease should first include taking 2) Infections 3) Diseases a detailed history. 4) Poisons 5) Medications 6) Nutritional Deficiency problems, pregnancy, psoriasis, ecze- which are often observed and treated 7) Normal Aging ma, vitamin deficiencies, nutritional by podiatric physicians and surgeons. disorders, lichen planus, onychogry- The gerontologist addresses the 1) Injuries that may cause a per- phosis, primary nail disorders, and effects of impaired circulation, mul- manent deformity in the nail unit neoplasms of the nail. tiple drugs, abnormal gaits as well include crushing the base of the as bone and joint changes in the nail, matrix, or nail bed. Chronic 127 elderly. The bony defects that affect picking or rubbing of the skin be- nail health and development are re- hind the nail plate can cause me- vealed by the orthopedist, podiatrist, dian nail dystrophy which causes and rheumatologist as well. The in- a lengthwise split or ridged appear- fectious disease specialist and my- ance of the nail plate. Long-term cologist are experts in revealing nail exposure to chronically walking or pathology rooted in fungal infections working in wet areas or wearing and diseases such as AIDS. Derma- wet shoes can lead to deformities tologists are familiar with every as- such as nail bed attachment prob- pect of nail pathology diagnosis and lems, brittle and peeling nails, as treatment, and are adept at recon- well as yeast and fungal infections

A basic cause of nail disease is Figure 4: Paronychia and bacterial infection of nutritional deficiency. toenail area

ciling the relationship of pathologi- of the toenails (Figure 1). cal nails, skin disease, and systemic To facilitate making a prompt conditions. and accurate diagnosis, the patient Podiatric physicians and surgeons should be asked to bring to the office are the specialists in the foot, which all nail-care products, soaks, soaps, includes the toenails. Their expertise and nail instruments that are used to embodies and encompasses each of care for the feet and nails, and have the medical professions that consider all nail polish removed. disease of the toenails their purview. Various cosmetics, nail polish, Podiatrists should therefore be con- chemical irritants, strong soaps, and sidered the definitive authorities in nail products can alter the chemistry the area of toenail disease, able to di- and pH of the toenails and surround- agnose and manage nail pathology in ing skin, and can adversely affect the a way that supersedes and surpasses health of the nail by causing allergic the approach, analysis, recommen- or contact irritation, allergy, inflam- dations, and outcomes of any other mation, a caustic or burn reaction to Figure 5: Splinter hemorrhages on the nail bed professionals who treat the nails. Continued on page 128 www.podiatrym.com MARCH 2015 | PODIATRY MANAGEMENT CME Continuing

Medical EducationNails (from page 127)

the skin, nail folds, and nail matrix (Figure 2). 2) Infections are a common source of nail deformities, nail loss, or changes in nail color. Fungus or yeast normally cause changes in the color, texture, and shape (Figure 3) of the nail. Bacterial infection can cause complete nail loss as well as a complete change in nail color, or a painful area of abscess, purulence, inflammation or redness under the nail or in or around the nail borders and skin (Figure 4). Splinter hemorrhages (Figure 5) (red streaks in the nail bed) result from certain infections of the heart valves. 3) Diseases There are many nail symptoms and primary nail diseases, as well as many systemic diseases that have Figure 7: Beau’s lines with permission from Dr. Mark Williams, University of Virginia 128 nail signs and symptoms as part of the clinical picture. There are almost cent research, it was thought that differences between nail changes in 400 medical conditions that cause nail changes occur infrequently in functional vasospastic arterial disease nail pathology. Therefore, getting a vascular disease—the exception was and organic arterial occlusion. good medical history can be quite thought to be confined mostly to ne- In all varieties of functional va- revealing and is the foundation of a crosis or ulceration in the nail of the sospastic disease, including Ray- good diagnosis of nail disease. affected digit. naud’s disease and phenomena, To elucidate and clarify the major Scleroderma, however, was scleroderma, peripheral neuritis, systemic causes of nail pathology, known to cause the nails to undergo leprosy, and sclerodactylia, a con- other than injuries or infections men- tioned above, the following categori- zation will prove helpful. * Disorders that affect the circu- Nail fold and cuticle changes are commonly seen lation to the limbs, or the amount of in vasospastic arterial disease. oxygen in the blood or delivered to the extremities are primary culprits of nail disease. The amount of oxygen in the atrophy, thickening, and deforma- dition called pterygium exists (Fig- blood can be decreased by the pres- tion. And recent research shows that ure 8). This is a condition where ence of certain types of heart abnor- in peripheral vascular disease, dis- there is a notable thinning of the malities, lung disease, cancer, or in- turbances are frequent, with Beau’s proximal nail fold, with a gradual fection; and if the nails are affected, lines indicating periods of retarded merging into the translucent cuti- the problems show up as clubbing growth, partial loosening, atrophy, cle. This epidermal membrane can (Figure 6). distortion, or finally destruction by advance as much as 3 millimeters Considering organic and func- gangrene (Figure 7). over the nail plate and can adhere tional arterial disease, up until re- There are, however, significant to its outer surface. Interestingly, this condition is very often a marker for impending scleroderma. This condition is also seen in onychophagia (Figure 1) (the practice of biting one’s nails) and commonly in the last two toenails in apparently normal persons. It is in- teresting to note that there is a fairly common normal form of pterygium, which is not characterized by thin- Figure 6: Clubbing of the toenails Continued on page 129

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Nails (from page 128) tally, sometimes over the whole nail tional vasospastic and organ- plate. The white spread is due to a ic vascular disease is related ning of the proximal nail fold. All buildup of a substance called kerato- to onycholysis, where the nail is nail changes can be reversed as the hyalin and explains the condition of loosened and painlessly shed. Infec- vasospasm is reversed. total leuconychia. tions of the nails and surrounding tissues, as well as chronic subungual infection seen in relation to ischemic Splinter hemorrhages osteomyelitis and associated subungual abscess, may be seen in all are usually associated with red streaks types of vascular disease to the extremities. Also, acral ulcerations may in the nail bed. involve the nail structures and show non-prejudice to the type of dysvascular conditions present. Nail changes in organic arterial Functional Vasospastic and It is important to note that the occlusive disease are a result of isch- Organic Vascular Disease nail changes discussed in relation emia. Whether the occlusive disease Nail pathology seen in both func- to organic and functional peripheral is arteriosclerosis or the less vascular disease are indeed common thromboangiitis ob- sensitive indicators of the se- literans, there is a marked verity of the disease. distortion of the nail plate. As part of the discussion There are no accompanying on peripheral vascular dis- nail fold and cuticle chang- ease of any type, the subject es seen in vasospastic dis- of painful nails should be ex- 129 eases. Linear growth of the amined. Nails themselves are nail plate is retarded such not painful. When a healthy that the nail does not have patient complains of painful Figure 8: Pterygium of toenails, with the typical nail changes in vasospastic to be trimmed for months or disease showing widening of the cuticle and thinning of the nail fold. nails, it is usually due to an even years. The nail plate ingrown toenail, infection, becomes thick, heavy, and abscess, subungual exostosis, rough. The roughening or trauma to the surrounding is due to transverse paral- tissues or underlying bone. lel ridging. The nail plate is When a dysvascular pa- usually darkened, either be- tient complains of painful cause of contained pigment nails, especially toenails, or soiling of the thick ridg- the clinical picture may be es. This thickened and dark- quite different. The patient ened nail plate obscures all may complain of pain on or visibility to the nail bed and around the nails, but the tis- can progress to a grossly de- sues are hyperesthetic, and formed claw nail, called ony- Figure 9: Typical nail changes in organic arterial disease showing ridging, the slightest pressure from chogryphosis (Figure 10). thickening, and discoloration of the nail plate due to ischemia any source, whether it is Reversal of the nail from shoes or just touching changes can take place if the the digit, gives rise to more occlusive disease is repaired, pain than expected. This is, and is often used as an indi- more often than not, inter- cator of the success of any preted as an ingrown toenail circulation augmentation causing the pain, whether therapy. there is an ingrown toenail there or not. Diffusion of the Lunula The nail symptoms here A condition called diffu- could be a result of ischemic sion of the lunula is due to hyperesthesia and have noth- pronounced ischemia. It is ing to do with the nail itself. very common in leprosy and Relief from pain of this sort other dystrophic conditions is obtained by cessation of affecting the circulation to weight bearing and increas- the extremities. This condi- ing the circulation to the tion is characterized by the digit. white lunula spreading dis- Figure 10: Severe dystrophic nail and onychodystrophy Continued on page 130 www.podiatrym.com MARCH 2015 | PODIATRY MANAGEMENT CME Continuing

Medical EducationNails (from page 129)

It is very important to consider the traumatic consequences of doing any type of definitive toenail pro- cedure on a patient with impaired circulation, such as necrotic changes to the digit. This is true if the patient really does have an ingrown toenail, but caution is especially warranted if the patient does not.

Kidney Disease Nails affected by kidney disease are damaged by the nitrogen buildup in the blood. This shows up in the nails as Beau’s Lines, koilonychia, leuconychia, and half-and-half nails (Figure 11).

Liver Disease Figure 11: Terry’s half and half nails indicative of kidney or liver disease. Permission from Pale nails (or white nails) can be Dr. Mark Williams a sign of liver disease. The liver man- 130 ufactures blood proteins and when run across the fingernails horizon- hemorrhages, telangiectasias, cap- this is abnormal, it shows up in the tally, have been linked to low levels illary loops in proximal nail folds, nails in this way. This condition can of the protein albumin, an important periungual erythema, and thin also indicate anemia, which is a com- component of blood that is made in nail plates are significantly more mon side effect of the medications the liver (Figure 12). common in patients with systemic used to treat hepatitis C. Terry’s nails, a condition marked lupus erythematosis than in per- Clubbing of the toenails can be by the tip of each nail having a dark sons without. In patients with systemic sclero- sis, periarteritis nordosa, Wegener Erythema in the proximal nail granulomatosis and dermatomyo- sitis/polymyositis, the diseases are fold is more common in persons with systemic punctuated by the presence of splinter hemorrages, capillary loops in lupus erythematosus. the proximal nailfolds, an increase in longitudinal curvature, transverse curvature, and a white dull color of a sign of decompensated liver dis- band, is potentially due to the liver’s the nail plates. In rheumatoid arthri- ease, which happens when the liver impairment in producing albumin. tis, splinter hemorrhages, red lunula, is damaged to the extent that it im- and white dull color are more com- pairs its functioning (Figure 6). Connective Tissue Disease and mon findings (Figure 13). Mee’s Lines or Muehrcke’s Lines, Collagen Disorders Proximal nail fold involvement is appearing as double white lines that Patients with this category of dis- a central finding in this set of diseas- orders common- es. A careful clinical examination of ly experience a the nail and a capillary microscopy wide gamut of nail study of the proximal nail fold may changes. These be diagnostic for these connective nail changes are tissue collagen disorders. so consistent, they can be used with Amyloidosis standard diagnostic Amyloidosis is a disease where tools to establish one or more body organs accumulate an accurate diag- insoluble proteins. It can be a sequel- nosis of a number la of inflammatory diseases such as of disorders. rheumatoid arthritis. The nails can Figure 12: Mee’s lines or Muehrcke’s lines can time the event from Erythema become flaky, crumbly, brittle, and location on the nail. These are associated with illness, heavy metal in the proximal dystrophic. poisoning or chemotherapy. nail fold, splinter Continued on page 131

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Nails (from page 130) is not from sun exposure, as com- • Periungual melanoma monly thought. when it originates from the Approximately 10% of peo- Melanoma of the nail unit, usu- skin adjacent to the nail plate. ple afflicted with lichen planus,a ally a variation of acral lentigionous T-Cell immunologic disease associ- melanoma (occurring on the palms of Hormonal Imbalance/Deficiency ated with Hepatitis C, develop re- the hands and the soles of the feet) Because the nails are dependent sultant nail pathology. This shows can also be part of nodular melano- upon proper protein synthesis, the up as pitting, longitudinal lines ma or desmoplastic melanoma. It is proper interplay and balance of the and linear depressions of the nail plate, as well as severe dystrophy and complete destruction of the nail bed. Proximal nail fold involvement is a central finding Skin Cancer and Melanomas The most common of the can- in connective tissue collagen disorders. cers that involve the nail unit is melanoma. Nail unit melanoma ac- counts for about 1% of melanomas associated with either the great toe- body’s hormones are fundamental to in white-skinned individuals. Acral nail or the thumbnail. the health of the nails. When there lentiginous melanoma is the most Melanoma of the nail unit can is hormone deficiency or imbalance, common type of melanoma diag- also be categorized as: the nails are affected. nosed in African-Americans and • Subungual melanoma when it Asians. It is usually diagnosed in originates from the nail matrix (Fig- Hypothyroidism persons between the ages of 40 and ure 15). Hypothyroidism can cause im- 131 70 years of age. It is thought to • Ungual melanoma (Figure 14) pairment to the digital circulation. arise from trauma, being most com- when it originates from the nail bed This can result in the nail beds ap- mon in the thumb and great toe. It under the nail plate, or pearing pale and dysvascular. Hyper- and hypothyroidism cause dry brittle nails, as well as softening of the nails A condition called and onycholysis. Brittle nails, which can be a marker for osteoporosis, diffusion of the lunula is due to pronounced a condition that is often coincident with diminishing estrogen levels, can ischemia. also be a reflection of menopause Continued on page 132

Figure 14: Nail apparatus melanoma

Figure 13: Splinter hemorrhages can be associated with connective tissue disease, and collagen disorders. By permission from Dr. Mark Williams Figure 15: Amelanotic subungual melanoma www.podiatrym.com MARCH 2015 | PODIATRY MANAGEMENT CME Continuing 8. Slideshow from Dr. Medical EducationNails (from page 131) Mark E. Williams Diseases of and/or osteoporosis. the finger nails University of Brittle nails also show up Virginia School of Medicine. in parathyroid hormone 9. Common nail changes and disorders in older peo- deficiency. Pregnancy ple Diagnosis and manage- can also result in brittle ment Lina Abdullah, RN Os- nails, as well as groove sama Abbas, MD Can Fam formation, split nails, Physician Feb 2011; 57 (2): and onycholysis. Verti- 173-181. cal lines on the nails are 10. Chamberlain A. Ng typically part of the clini- J. Cutaneous melanoma- cal picture of growth hor- Atypical variants and pre- mone deficiency. sentations. Australian Fam Physician. 2009 Jul; 38 (7): 476-482. Diabetes Mellitus 11. Ruben BS. Pigment- Although diabetes ed Lesions of the Nail Unit: mellitus is a result of a Clinical and Histopathologi- hormone abnormality, cal Features Seminars in Cu- the importance of this Figure 16: Yellow nails and longitudinal ridging in diabetes mellitus. taneous Medicine and Sur- condition warrants a gery 2010; 29 (3): 148-158. category by itself. It is generally teemed Dr. Phil Gardner, may he rest 12. Boni E. Elewski Onychomyco- thought, although oft-disputed, that in peace, that “given a good enough sis: Pathogenesis, Diagnosis, and Man- 132 persons with diabetes mellitus are history, the patient will actually tell agement Clinical Microbiol Rev Jul 1998; at higher risk for onychomycosis. you what is wrong; you just have to 11(3): 415-429 13. Abstract of Study an Assessment Kidney disease and peripheral vas- listen!” PM of the human nail plate pH cular disease, as previously dis- Milcovich and G.S. Goriparthi Department cussed, have their effects on the Bibliography of Pharmaceutics, School of Pharmacy, nails and are commonly part of the 1. Zaias, N. The nails in health and University of London. diabetes syndrome. Peripheral neu- disease. Norwalk (CT): Appleton & Lange, 14. Piraccini BM. Tosti A. Drug-in- ropathy, aside from the vascular 1990. duced nail disorders: incidence, management and prognosis. Drug Safety 1999 Sep; 21 (3): 187-201. 15. Seshadri D, De D. Nails in nu- Vertical lines on the nails tritional deficiencies. Indian J Dermatol are typically part of the clinical picture of growth Venereol Leprol 2012; 78: 237-41. 16. Julie Jefferson and Phoebe Rich. hormone deficiency. Review Article Melanonychia Dermatol- ogy Research and Practice Volume 2012 (2012), Article ID 952186, 8 pages. 17. Tosti A. The nail apparatus in component of diabetes, can man- 2. Baden HP. Diseases of hair and collagen disorders Semin Dermatol 1991 ifest itself as dry skin and brittle, nails. Chicago: Year Book Medical; 1987. Mar; 10 (1): 71-6. dry nails. 3. Kosinsky MA, Steward D. Nail 18. Holzberg M, Walker HK. Terry’s Longitudinal ridging and yel- changes associated with systemic disease nails: revised Definition and new correla- and vascular insufficiency in clinics in low toenail syndrome is a common tions. Lancet. 1984; 1(8382): 896-9. podiatric medicine and surgery. Clin Podi- 19. Rubin Al, Baran R. Physical finding in patients with diabetes atric Med Surg 1989;2: 302. signs. In: Baran R, de Berker D, Hol- mellitus (Figure 16), Due to the 4. Fenton DA. Nail Disorders associ- zberg M, Thomas L(eds). Baran and fact that podiatric physicians and ated with associated with general medi- Dawber’s Deiseases of the Nails and surgeons are so well-versed in the cal conditions. In: Sammon PD, Fenton their Management, fourth edition, chap- workup of the diabetic patient, DA, editors. The nails in disease. London: ter 2, Wiley-Blackwell. more detail is not warranted in this Heinemann Medical; 1998. P. 102-7. 5. Abraham J. Herzberg, DPM,Nail discussion. Dr. Rehm is Medical Manifestations of systemic disease Clin The three most common caus- Director, The Dia- Podiatr Med Surg 21 (2004) 631-640. es of nail diseases have been care- betic Foot & Wound 6. Richard K. Scher C Ralph Daniel fully discussed. However, there Treatment Centers San III Nails Diagnosis Therapy Surgery Third Marcos, California. He are four more culprits of nail pa- Edition Elsevier Saunders. is Board certified by thology that need to be presented 7. Nail Changes in Functional and Or- the American Board of in this paper. ganic Arterial Disease Edward A. Edwards Multiple Specialties in The reader would benefit from M.D. N Engl J Med 1948 239: 362-365 Podiatry. the recurring utterance of the es- September 2, 1948.

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See answer sheet on pagE 135.

1) The following condition is 6) Nail fold and cuticle 11) The following should be most often associated with toe- changes are commonly seen considered in a patient com- nail disease that mimics ony- in: plaining of painful toenails: chomycosis: A) Organic occlusive A) Nails themselves are not A) Pterygium disease painful B) Psoriatic nail disease B) Vasospastic arterial B) Referred pain from C) Hailey-Hailey disease disease neuromas D) Darier’s disease C) Thromboangiitis C) Hypothyroidism obliterans D) Kidney disease 2) The following medical spe- D) Venous insufficiency cialty is most likely to incor- 12) Nails affected by kidney porate nail pathology in their 7) Peripheral vascular disease are damaged by practice? disease is associated A) Carbon dioxide buildup A) Gastroenterology with: in the blood B) Hematology A) Transverse parallel B) Elevated AST in the C) Virologist ridging blood D) Geneticist B) Onychogryphosis C) Nitrogen buildup in the 133 C) Beau’s lines blood 3) An initial diagnostic work-up D) All of the above D) Low ALT enzymes of toenail disease should first include ____. 8) Pterygium is commonly 13) Beau’s Lines, half-and-half A) Taking a detailed history associated with the following: nails and/or leuconychia are a B) Clipping of the toenail A) Irreversible nail common problem in: C) Removal of toxic nail changes A) Liver disease polish B) Onychocryptosis B) Osteoporosis of the distal D) Identification of any in- C) Sclerodactylia phalynx grown nail borders D) Thickening of the C) Bowen’s disease proximal nail fold D) Kidney disease 4) A basic cause of nail disease is: 9) Diffusion of the lunula is 14) The following are associated A) Talipes equinus due to the following: with liver disease: B) Uncompensated rearfoot A) Extensive osteo- A) Pale nails varus arthritic spurring B) Clubbing of the toenails C) Nutritional deficiency B) Nail bed melanoma C) Mee’s lines D) Abnormal shoe wear C) Pustular psoriasis D) All of the above D) Pronounced ischemia 5) Permanent deformity of the 15) Splinter hemorrhages are nail unit is most likely caused 10) Acral ulcerations are usually associated with by commonly associated A) Red streaks in the A) Rheumatoid arthritis. with: nail bed B) Raynaud’s disease and A) Only certain types of B) A foreign body phenomena. dysvascular conditions C) Retinal bleeding C) Onychophagia. B) Deeper nail structures D) Abnormal prothrombin D) Long-term exposure to C) Peripheral vasodilation time wet areas. D) Hyperesthesia Continued on page 134 www.podiatrym.com MARCH 2015 | PODIATRY MANAGEMENT $ CME EXAMINATION PM’s Continuing

Medical Education CME Program 16) Which nail disorders are more common in persons with systemic lupus Welcome to the innovative Continuing Education erythematosus? Program brought to you by Podiatry Management A) Increase in longitudinal curvature Magazine. Our journal has been approved as a of the nail plate sponsor of Continuing Medical Education by the B) Dull white color of the nail plate Council on Podiatric Medical Education. C) Erythema in the proximal nail fold D) Ingrown toenails Now it’s even easier and more convenient to enroll in PM’s CE program! 17) Proximal nail fold involvement is a You can now enroll at any time during the year central finding in: and submit eligible exams at any time during your A) Nail bed malignancies enrollment period. B) Cardiovascular diseases PM enrollees are entitled to submit ten exams C) Pulmonary diseases published during their consecutive, twelve–month enrollment period. Your enrollment period begins D) Connective tissue collagen with the month payment is received. For example, disorders if your payment is received on November 1, 2014, your enrollment is valid through October 31, 2015. 134 18) The most common of the malignancies If you’re not enrolled, you may also submit any that involve the nail unit is: exam(s) published in PM magazine within the past A) Bowen’s disease twelve months. CME articles and examination B) Melanaoma questions from past issues of Podiatry Manage- C) Squamous cell carcinoma ment can be found on the Internet at http:// D) Lentiginous melanoma www.podiatrym.com/cme. Each lesson is approved for 1.5 hours continuing education contact 19) Melanoma of the nail bed is best hours. Please read the testing, grading and payment characterized as: instructions to decide which method of participa- A) Subungual, ungual or periungual tion is best for you. B) Superficial, deep, or intermediate Please call (631) 563-1604 if you have any ques- C) Subacute, acute, or chronic tions. A personal operator will be happy to assist you. D) Subclinical, clinical, or dormant Each of the 10 lessons will count as 1.5 credits; thus a maximum of 15 CME credits may be earned 20) Vertical lines in the nail plate are during any 12-month period. You may select any 10 typically part of the clinical picture in a 24-month period. of _____. A) Hyperthyroidism The Podiatry Management Magazine CME B) Hypothyroidism program is approved by the Council on Podiatric C) Growth hormone deficiency Education in all states where credits in instructional D) Parathyroid hormone deficiency media are accepted. This article is approved for 1.5 Continuing Education Contact Hours (or 0.15 CEU’s) for each examination successfully completed.

Home Study CME credits now See answer sheet on page 135. accepted in PennsylvaniaContinued on page 134

MARCH 2015 | PODIATRY MANAGEMENT $ MedicalC ontinuingEducation Enrollment/Testing Information and Answer Sheet Note: If you are mailing your answer sheet, you must complete all rolled in the annual exam CME program, and we receive this exam info. on the front and back of this page and mail with your credit card during your current enrollment period. If you are not enrolled, please information to: Podiatry Management, P.O. Box 490, East Islip, send $25.00 per exam, or $195 to cover all 10 exams (thus saving $55 NY 11730. over the cost of 10 individual exam fees). Testing, Grading and Payment Instructions Facsimile Grading (1) Each participant achieving a passing grade of 70% or higher to receive your CME certificate, complete all information and fax on any examination will receive an official computer form stating the 24 hours a day to 1-631-563-1907. Your CME certificate will be dated number of CE credits earned. This form should be safeguarded and and mailed within 48 hours. This service is available for $2.50 per exam may be used as documentation of credits earned. if you are currently enrolled in the annual 10-exam CME program (and (2) Participants receiving a failing grade on any exam will be noti- this exam falls within your enrollment period), and can be charged to fied and permitted to take one re-examination at no extra cost. your Visa, MasterCard, or American Express. (3) All answers should be recorded on the answer form below. if you are not enrolled in the annual 10-exam CME program, the For each question, decide which choice is the best answer, and circle fee is $25 per exam. the letter representing your choice. Phone-In Grading (4) Complete all other information on the front and back of this page. You may also complete your exam by using the toll-free service. (5) Choose one out of the 3 options for testgrading: mail-in, fax, Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Monday through or phone. To select the type of service that best suits your needs, Friday. Your CME certificate will be dated the same day you call and please read the following section, “Test Grading Options”. mailed within 48 hours. There is a $2.50 charge for this service if you are Test Grading Options currently enrolled in the annual 10-exam CME program (and this exam 135 Mail-In Grading falls within your enrollment period), and this fee can be charged to your to receive your CME certificate, complete all information and Visa, Mastercard, American Express, or Discover. If you are not current- mail with your credit card information to: ly enrolled, the fee is $25 per exam. When you call, please have ready: 1. Program number (Month and Year) Podiatry Management 2. The answers to the test P.O. Box 490, East Islip, NY 11730 3. Your social security number PLEASE DO NOT SEND WITH SIGNATURE REQUIRED, AS 4. Credit card information THESE WILL NOT BE ACCEPTED. in the event you require additional CME information, please there is no charge for the mail-in service if you have already en- contact PMS, Inc., at 1-631-563-1604.

Enrollment Form & Answer Sheet Please print clearly...Certificate will be issued from information below.

Name ______Soc. Sec. #______Please Print: First MI Last Address______City______State______Zip______Charge to: _____Visa _____ MasterCard _____ American Express Card #______Exp. Date______Note: Credit card is the only method of payment. Checks are no longer accepted. Signature______Soc. Sec.#______Daytime Phone______State License(s)______Is this a new address? Yes______No______

Check one: ______I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be charged to your credit card.) ______I am not enrolled. Enclosed is my credit card information. Please charge my credit card $25.00 for each exam submitted. (plus $2.50 for each exam if submitting by fax or phone). ______I am not enrolled and I wish to enroll for 10 courses at $195.00 (thus saving me $55 over the cost of 10 individual exam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone.

www.podiatrym.com Over, please MARCH 2015 | PODIATRY MANAGEMENT Enrollment Form & Answer Sheet (continued) Continuing

Medical Education

EXAM #2/15 Nails—They Mean More Than You Think!—Part 1 (Rehm)

Circle: 1. A B c D 11. a B c D 2. A B c D 12. a B c D 3. A B c D 13. a B c D 4. A B c D 14. a B c D 5. A B c D 15. a B c D 6. A B c D 16. a B c D 7. A B c D 17. a B c D 8. A B c D 18. a B c D 9. A B c D 19. a B c D 136 10. a B c D 20. a B c D

Medical Education Lesson Evaluation

Strongly Strongly agree Agree neutral Disagree disagree [5] [4] [3] [2] [1]

1) This CME lesson was helpful to my practice ____

2) The educational objectives were accomplished ____

3) I will apply the knowledge I learned from this lesson ____

4) I will makes changes in my practice behavior based on this lesson ____

5) This lesson presented quality information with adequate current references ____ 6) What overall grade would you assign this lesson? ABCD How long did it take you to complete this lesson? ______hour ______minutes

What topics would you like to see in future CME lessons ? Please list : ______

MARCH 2015 | PODIATRY MANAGEMENT www.podiatrym.com