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Objectives and Goals 1) To reframe the importance of pathology in clinical practice. 2) To appreciate the diagnostic opportunities available through a good history and physical in a patient with . 3) To be able to create an astute differential diagnosis through careful investigation of Nails—They Mean nail pathology. 4) To understand the signif- icance of proper diagnosis and More Than You treatment of nail disorders. 5) To be able to identify med- ical conditions and co-morbid- ities that accompany different 153 Think!—Part 2 nail conditions. 6) To define the parameters of the decision-making process of treating diseased toenails in Here’s how to nail down a good examination! clinical practice. 7) To empower the podiatric physician to consider the whole By Kenneth B. Rehm, DPM patient when developing a treat- ment 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. 164. 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. 164).—Editor

he toenails, like the finger- thology, and therefore can be used part of the examination. Different nails, reflect the balances as trusted markers for a myriad of diseases were discussed in relation and imbalances present in medical problems. If we understand to its impact on nail health. Part II the body, and therefore the language of the toenail, we would will complete the history-taking nar- the condition of the nails appreciate its profound importance in rative and delve into the sometimes Tmirrors the condition of the body. diagnosis and treatment. This paper indistinct borders of diagnostic cat- Conversely, medical problems are attempts to give us this insight. egories. The journey concludes with commonly revealed through nail pa- Part I took us through the history Continued on page 154 www.podiatrym.com JUNE/JULY 2015 | PODIATRY MANAGEMENT CME ducation ontinuingE C edical M Nails (from page 153)

a suggested protocol to be used on patients with nail disease. Besides diseases that impart their signature features to the nails, there are other conditions that lend their impact as well. These are conditions such as poi- soning, effects of medications, nutri- tional and vitamin deficiencies, and normal aging. They will be discussed here.

I. Conditions Affecting Nail Health

1) Poisoning The most common poisons in- gested that affect the nails involve heavy metal poisoning. Arsenic causes the nails to develop horizontal ridg- Figure 2: Beau’s Lines: Courtesy of Mark Williams M.D. University of Virginia. Transverse depressed es, white lines and Mees’ lines (Fig- ridges seen in severe infection, MI, hypotension/shock, hypocalcemia, post-surgical, malnutrition and ure 1), representing white bands of with certain . 154 arsenic deposits across the nail bed, which can be present several weeks 2) Medications very individual in nature, depending to months after the acute poisoning The most consistently harmful im- on the condition of the patient. The event. Clubbing of the nails can be pact on the nails is through the cancer most offensive of these drugs are the caused not only by arsenic but also by drugs. These side-effects are in direct biological therapy drugs comprising phosphorous, alcohol, mercury, beryl- proportion to the dose and the com- the chemotherapy. The way these lium, and vinyl chloride. bination of drugs being used, and are side-effects show up in the nails is that they become brittle, dry, thin, and slow growing, sometimes with ridging, dark lines, or white discolor- ations. The nails may become darker in color or loose, to the point of even falling off. Beau’s lines (Figure 2), on- ychomadesis (transverse whole thick- ness sulci which divide the nail in half), and true transverse can occur in association with cancer chemotherapy and reflect the toxicity of these substances on actively divid- ing tissues; and is a symptom of tran- sient impairment of nail matrix kera- tinization. Although any chemothera- peutic medications can be responsible for these adverse effects on the nails, cyclophosphamide, doxorubicin, and vincristine are more likely to cause leukonychia. Other drugs, such as and retinoids can cause nail disease by interfering with normal keratini- Figure 1: Courtesy of Mark Williams M.D. University of Virginia: Mees’ Lines are transverse white zation of the nail matrix, frequently lines (usually one per nail, no depressions) that often disappear if pressure is placed over the line. It is causing Beau’s lines, onychomade- strongly associated with , thallium poisoning and to a lesser extent other heavy metal poisoning, chemotherapy or illness and can time the event from the location on the nail. sis and . In the case of Muehrcke’s Lines (Leukonychia striata): Narrow white transverse lines (not depressed, com- retinoids, drug-induced formation of pared to Beau’s lines). Usually 2 or more lines on one nail. Seen in states of decreased protein syn- granulation tissue and nail brittleness thesis or increased protein loss such as with hypoalbunemia (usually less than < 2.2 g/dL), certain can lead to the development of pyo- chemotherapy and nephrotic syndrome. Continued on page 155

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Nails (from page 154) Drug-induced on one coloration is associated with or more nails usually develops soon antimalarial agents. The skin, genic granulomas and ingrown nails after the administration of the offend- sclera and mucous membranes can with hypertrophic unguilabia. ing medication, commonly metho- also be affected with minocycline and Drug-induced onycholysis can re- trexate, retinoids, and in HIV-infected anti-malarials. Nail discoloration some- sult from damage to the nail bed epi- patients receiving multiple-drug thera- times persists unchanged for years thelium with loss of nail plate adhesion, py, including the nucleoside analogue after discontinuing the drug; however, which can follow complete destruction lamivudine and/or the protease inhib- more often than not, these conditions of the nail bed epithelium with conse- itor indinavir. regress spontaneously when the medi- cations are discontinued. Drug-induced nail changes are The most common poisons quite widespread. In addition to the well-recognized causative agents, nu- ingested that affect the nails merous other drugs have occasionally been associated with the development involve heavy metals. of nail abnormalities. Knowing these side-effects and their cause is import- ant in preventing these sometimes quent hemorrhagic bullae. A number of These drugs can also indirectly devastating outcomes. drugs can cause this destruction, includ- cause nail damage by damaging the ing cancer chemotherapeutic agents, blood vessels to the nail unit and im- 3) Nutritional and Vitamin retinoids, psoralens, and gold. pairing its circulation, thereby causing Deficiency necrosis of the nail apparatus. This Nails are important cosmetically, Photo-onycholysis manifests as splinter hemorrhages or but they also reflect a person’s health, 155 A condition called photo-ony- subungual hematomas. Drug-induced body chemistry, and nutritional status. cholysis results from a photo-medi- problems of the nails are more likely It can be said that almost any ated allergic or toxic reaction to the to be caused in those toenails which nutritional deficiency can produce nails and surrounding skin. Preven- receive a lot of trauma or pressure changes in the nail plate and some- tion of this condition involves avoid- from shoes. times in the nail bed. ing exposure to sunlight while taking Bleomycin, an anti-cancer chemo- Poor food and water intake, espe- the drugs, as with tetracycline. therapy drug, is associated with Ray- cially in the elderly, are responsible naud’s phenomenon in up for brittle nails. Brittle nails are also to 37% of patients. This and commonly seen in patients with an- other drugs, including be- orexia nervosa. ta-blockers, can also cause Malnutrition can be associat- digital gangrene. With be- ed with nails that are soft and thin, ta-blockers, however, this as well as longitudinal melanychia. side-effect is most common Muehrcke’s lines (Figure 1) are com- in patients who already monly associated with hypoalbumin- have peripheral vascular emia. This type of leukonychia can disease. It is thought to re- either be apparent leukonychia: white sult from decreased cardiac transverse bands that reflect abnormal output that is not efficiently nail bed circulation that fades on pres- balanced by peripheral va- sure; or true leuconychia that reflects Figure 3: Terry’s Nails (White Nails) sodilation, particularly with an abnormal nail plate. Terry’s nails, non-cardioselective agents, although classically associated with which then leads to impaired distal liver disease, can be a manifestation perfusion. Symptoms are not always of malnutrition as well (Figure 3). reversible when the drug is discon- Beau’s lines are among the most tinued and amputation of the digit or common of nail signs of nutritional limb is often needed. deficiencies, including protein defi- Excretion or deposition of the drug ciency and the general malnourished in the nail plate causing discoloration state associated with chronic alcohol- is a common consequence of various ism. Protein deficiencies are also as- medications. Yellow discoloration is sociated with dystrophic nails that caused by tetracycline or gold salts. undergo onycholysis, onychoschizia Dark-brown discoloration is common and onychomadesis with a resultant Figure 4: Triangular Residual Nail Plate with after using clofazimine; blue-grey dis- peculiar, triangular residual nail plate absence of lunula associated with protein defi- coloration is a result of using mino- (Figure 4). ciency, anemia and malnutrition cycline; and blue, brown or grey dis- Continued on page 156 www.podiatrym.com JUNE/JULY 2015 | PODIATRY MANAGEMENT CME ducation ontinuingE C edical M Nails (from page 155)

Koilonychia (Figure 5), an abnor- mality in the curvature of the nail, is a classic sign of iron-deficiency anemia. can also result in brittle nails, onycholysis and (longitudinal splitting of the nails). A central nail ridge is usually caused by folic acid deficiency, pro- tein deficiency, or iron deficiency. Io- dine deficiency can also result in club- bing of the nails. Hypocalcemia can result in brittle nails, transverse leuconychia, ony- chomadesis (complete nail shedding starting from the proximal attachment of the nail), longitudinal splitting of the nails (onychorrhexis), longitudinal striations, and soft nails (hapalony- chia), which are common in other nu- tritional abnormalities, as well. is associated with Figure 5: Courtesy of Mark Williams M.D. University of Virginia: Spooned nails or 156 brittle nails, onychorrhexis, white spots on the nails, ridging, and beau’s lines. Vitamin C deficiency is associated nail plate occur, therefore changing Prolonged total parenteral nutri- with koilonychia (Figure 5) and ha- the consistency and surface of the tion (TPN) is a risk factor for seleni- palonychia. Exhaustive studies have nails. As part of normal aging, there- um deficiency, which results in gener- been done on the role of vitamin sup- fore, non-pathological changes that alized leuconychia. plementation for the improvement occur in the nails are changes in color Persons with magnesium deficien- of nail health in a well-nourished (becoming dull, yellow, and opaque), cy develop soft, flaky nails that are healthy person. There is no evidence increased dryness and brittleness, lon- inclined to break and split. that supplements are effective in this gitudinal lines on the nail plate, on- Nail changes in vitamin deficien- cies should also be considered. Hapal- onychia (soft nails) has been associat- ed with deficiencies of both vitamin A In onychomadesis, the transverse and vitamin D, which also causes lon- whole thickness sulci divides the nail in half. gitudinal melanonychia. If the para- thyroid gland is underactive, there is a functional Vitamin D deficiency that causes brittle nails. regard. Brittle nail syndrome can, ychoclavus (a corn at the end of the It is interesting to note that cor- however, benefit from high dose bi- nail plate) and (thickening recting the nutritional deficiencies otin or silicon. Adequate intake of of the toenails). There may be ony- often reverse the adverse nail effects. essential vitamins and minerals facili- chomycosis, onychocryptosis, subun- Vitamin B deficiencies can man- tates nail health. gual hematomas, and paronychia. ifest in a wide variety of nail abnor- These common nail changes in malities such as: 4) Normal Aging the elderly, although for the most part • Transverse leuconychia Normal aging is associated with non-pathologic, can be painful, of cos- • Beau’s lines many health-related factors including: metic concern, and may affect mobil- • Onycholysis • Changing hormonal status ity, daily activities, and lifestyle. As • Half and half nails • Changes in cardiovascular and such, it is important to consider their • Hapalonychia venous status prevention and treatment, rendering • Dystrophic nails • Problems with dehydration the ravages of aging less formidable. • Onychoschizia • Changes in protein metabolism • Nail discolorations are actually • Changes in nutritional status II. Examining the Patient abnormalities of melanogenesis and • Dermatologic changes The same professional process show up as: • Arthritic changes of examination should be in place, – Longitudinal leuconychia In general, with advancing age, whether the patient’s chief complaint – Diffuse bluish discoloration or normal characteristic changes in the deals with nail problems, or with – Reticulate pigmentation. growth rate and morphology of the Continued on page 157

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Nails (from page 156) nail pathology in any portion of the Some of the more com- nail apparatus is essential in making mon nail conditions referred to, any other seemingly more important a correct diagnosis of a nail disorder. or discussed so far in this paper, complaints; as the nails can be reflec- Important findings relate to: which necessitate inclusion not only tion of many disorders that, without 1) Nail plate size in the history portion of the exam but this important marker, might other- 2) Abnormalities of nail shape the physical and podiatric exam as well, include the following:

Drug-induced paronychia on one or more nails Clubbing of the Nails Clubbing of the nails is an en- usually develops soon after the administration of the largement of the transverse and lon- gitudinal arc of the nails with hyper- offending medication. trophy of the underlying soft tissues; whereby the tips of the fingers enlarge and the nails curve around the finger- wise present a diagnostic nightmare. 3) Abnormalities of nail color tips, usually over the course of years Through evaluation of the nails on the 4) Abnormalities of the nail sur- (Figure 6). hands and feet, the astute examiner face and texture This condition can be classified of the nails would appreciate the op- 5) Abnormalities of the nail bed, into three types: portunity to uncover contextual back- folds, and lunula 1) Acquired ground information regarding the pa- 6) Other processes around the 2) Hereditary/congenital and tient, affording a diagnostic advantage nails, such as infectious or dermato- 3) Idiopathic to the investigator. This would include logic conditions (Figure 8) The acquired form is the most findings such as: 7) Comparison of right side vs. common cause of clubbing. Thoracic 157 • Overall vitality left, and hands and fingernails vs. feet problems account for about 80% of • Inner emotional state and toenails cases and gastrointestinal problems • Cerebral dominance Abnormal or diseased finger and account for about 5% of nail club- • Occupations and hobbies toenails should be looked for in the bing; however, it is most commonly • Past examination part as well as in the the result of low oxygen in the blood • Nutritional status history part of the H&P. A previous and could be a sign of various types • Cardiovascular function or current diagnosis of nail disease of lung disease, including lung can- • Rheumatic conditions can be very revealing in the history cer, , , and • Dermatologic problems part of the exam, not only to facili- . is also As with other vital portions of the tate the treatment of the nail problem associated with inflammatory bowel physical exam, recognizing signs of itself, but also to assist in the diag- disease, such as Crohn’s disease and nosis of associated , celiac disease, as- medical conditions. It bestosis, liver and thyrotox- is interesting to note, icosis, cardiovascular and cyanotic if not obvious, that congenital heart disease, liver disease, nail disease will affect and AIDS. both the hands and may be as- the feet, but may be sociated with , such more clinically visible as chronic , bronchiectasis, in either. and pleural effusion. There is also an Before discussing association with Hodgkin’s lympho- further pathology, ma, thyroid disease, diabetes mellitus, the reader must be , uterine cancer, malignant reminded of what to melanoma, lymphoma, and lymph- look for in a normal edema. nail. Considerations of the nail folds or include: the softness fluffy nail folds may be caused by and flexibility of the a connective tissue disorder such as free edge, the shape systemic lupus erythematosus or bac- and color, the quali- terial and fungal infections. ty of paronychial tis- “Half and half” nails (Figure 7) sues, and the growth with the proximal part of the nail rate, which should be white to pink and the distal half of about six months from the nail red to brown may be caused cuticle to free edge. by chronic renal failure and cirrhosis Figure 6: Clubbing of the Toenails Continued on page 158 www.podiatrym.com JUNE/JULY 2015 | PODIATRY MANAGEMENT CME ducation ontinuingE C edical M Nails (from page 157)

and vitamin B deficiency. Pitting of the nails or rippling of the nails show up as small depres- sions in the nail plate or ripples on the nail plate (Figure 9). Although nail pitting and rippling can be seen in about two thirds of healthy patients, these conditions are more pronounced in people who have psoriasis, inflam- matory or rheumatoid , and connective tissue collagen disorders such as Reiter’s syndrome and Alope- cia areata, an autoimmune disease that causes , as well as systemic lupus erythematosis. Discoloration of the nail is commonly associated with pitting, as well as the nail bed turning reddish-brown. Spoon nails (koilonychia) (Figure Figure 7: Terry’s Half and Half Nails. Courtesy of Mark Williams, MD University of Virginia 5) are soft nails that look scooped out like a spoon. The crater is usually as hemochromatosis. Spoon nails can a white color and the normal pink 158 able to hold a drop of liquid. If a drop also be associated with heart disease color and the tip of each nail develop of water cannot roll off the nail, it and hypothyroidism. a dark band. Sometimes, this can be is spooned. Often, spoon nails are a Terry’s nails (Figure 3) are some- attributed to aging. In other cases, it sign of iron deficiency anemia, times referred to as white nails syn- can be a sign of a serious underlying disease, or a liver condition known drome or leukonychia. The nails turn Continued on page 159

Figure 8: Processes around the nail: Swelling, Masses, Periungual Telangiectasia

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Nails (from page 158) nary disease or emphysema; or heart Subungual Melanoma problems. Because subungual melano- condition, such as cirrhosis, heart dis- Black, brown or dark lines under ma is such a critical and life-threat- ease such as congestive heart failure, the nail (Figure 10) are sometimes ening finding, more detail is warrant- diabetes, renal failure, arsenic poison- caused my malignant melanoma. Ex- ed in this discussion regarding the ing, malnutrition, , hypoal- treme caution should be under taken examination of this entity. buminemia and actinic keratosis. when this finding is present. The Beau’s lines are depressions that term melanychia is used to describe Examining Subungual Melanoma run across the nails (Figure 2). These a discoloration under the nail caused What does melanoma of the nail indentations could indicate areas of by melanin-derived brown-to-black unit look like (Figure 10)? retarded grown or can appear when nail pigmentation. Melanychia most Subungual melanoma can present the nail matrix and therefore nail often occurs due to benign etiologies in a variety of ways. It can start out growth is affected by injury or severe illness. Conditions associated with Beau’s lines include kidney disease, uncontrolled diabetes, and peripheral The risk of metastasis and death from subungual vascular disease, as well as illnesses melanoma is proportional to the thickness associated with a high fever, such as scarlet fever, , mumps, and of the melanoma and the completeness of excision. pneumonia. Beau’s lines can occur during or after chemotherapy or as a cause of a nutritional deficit such as such as activation, hyperplasia, or in- appearing as a paronychia, an indent- zinc deficiency. fection of the melanocytes associated ed nail, or a dark streak. It usually with the nail unit. The most serious starts out as a pigment band visible 159 disease, however, that presents with the length of the nail plate. As the Onychomycosis or fungal nail in- melanychia is subungual melanoma. disease progresses over the weeks fection is often associated with the This can have various presentations, and months, this pigment band gets elderly or people with underlying dis- but in clinical practice and in prac- wider, especially at its most proximal ease states such as peripheral vas- ticality, if the discoloration of the end and the cuticle. It becomes more cular disease, diabetes, immune sys- nail extends proximally into the skin variegated in color from light to dark tem problems such as HIV infection, fold, there should be a high index of brown. Ulcerations, nodules, subun- immunosuppressive medications, or suspicion of subungual melanoma. gual bleeding, and/or nail dystrophy cancer. Tinea pedis is considered a Also, Addison’s disease can cause may develop. high risk factor for mycotic toenails. longitudinal brown lines in the nail It is important to note that up to In healthy people, fungal nails are apparatus. Otherwise, the discolor- half of all cases of subungual mela- most commonly contracted through ation under the nail is usually caused noma are amelanotic (Figure 10), and moist wet areas such as communal by a benign event, such as trauma can present as a nodule under the nail showers at the gymnasium, or swim- resulting in dry blood or subungual plate, onycholysis, or verrucous. ming pools. In addition, artificial nails hematoma. Continued on page 160 can lead to fungus of the toenails. Cracked, dry, peeling and split- ting nails are often associated with long-term exposure to moisture, nail polish, and nutritional and dietary de- ficiencies. These nails have also been linked to thyroid disease. If the nails have a yellowish tint, they may be onychomycotic. Pale nails is a condition where the nail beds have lost their healthy pink luster associated with good circula- tion. This often indicates the presence of a condition such as anemia, con- gestive heart failure, liver disease, or malnutrition. Bluish nails is a condition where the nail beds are not getting sufficient circulation and are becoming cyanot- ic. This is often a sign of lung disease, such as chronic obstructive pulmo- Figure 9: Nail Pitting www.podiatrym.com JUNE/JULY 2015 | PODIATRY MANAGEMENT CME ducation ontinuingE C edical M Nails (from page 159)

Subungual melanoma is usually painless unless the tumor involves the underlying bone, causing severe pain. It is important to note that diag- nosis is confirmed by biopsy; and the melanoma must be removed surgically. The risk of metastasis and death is proportional to the thickness of the melanoma and the completeness of excision. Delay in the diagnosis and treatment is a risk factor for the tu- mors spreading at the time of diagno- sis. The quicker and more complete the treatment, the better the survival rate, which, according to some ex- perts, approaches 87%.

Onycholysis Onycholysis is a condition that describes the painless separation of 160 the nail plate from the nail bed start- ing distally. It is commonly associat- Figure 10: Different Presentations of Malignant Melanoma in the Nail ed with hyper- and hypothyroidism. When present, it affects the fourth fin- can show up commonly in Raynaud’s ed with anxiety or obsessive-compul- ger most often, followed by the fifth disease and diabetes mellitus. sive disorder. finger, remaining fingers, the thumb, and any or all of the toenails. This Gnawed Nails Splinter Hemorrhages condition is associated with alopecia Gnawed Nails (Figure 1, Part I) Splinter hemorrhages (Figure 5, universalis as an early marker of am- are the result of a person biting their Part I) describe a condition that re- yloidosis and multiple myeloma. It nails. This condition is often associat- Continued on page 161

Figure 11: Nail Presentations of Systemic Disease

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Nails (from page 160) is the complete absence (Figure 4), ment. Making a diagnosis re- usually caused by anemia, or mal- quires careful thinking. Now, flects the hemorrhaging of the distal nutrition. Secondly, there is a pyra- we can order diagnostic tests to capillary loops of the nail bed. It can mid-shaped lunula, normally caused confirm our working diagnosis to be caused by trauma or by systemic by some type of trauma, including arrive at our definitive diagnosis. The disease. Most commonly (41%), it is over-aggressive manicures or ped- choice of diagnostic tests to confirm associated with cardiovascular dis- icures. Thirdly, a red discoloration our working diagnosis (or diagnoses) ease, renal failure (12%), diabetes mellitus (10%), or pulmonary pathol- ogy (10%). Otherwise (27%), it can be associated with sub-acute bacte- “Half and half” nails are rial , renal , characterized by the proximal part white to pink, rheumatoid arthritis, scurvy, severe anemia, systemic lupus erythematosis, and distal nail red to brown. psoriasis, , and trichinosis. A final note on the physical exam of the lunula heralds cardiovascular is purely up to the clinical judgment as it relates to a chief complaint re- disease, collagen vascular disease, or of the practitioner; and may include lating to the nails: it is not only pru- hematological malignancy. imaging studies, circulation studies, dent but essential to also evaluate the blood tests, lab examinations such as skin, hair, and mucous membranes III. Making the Diagnosis: Putting KOH, Wood’s light, biopsies, as well so that findings can be put in better It All Together as fungal and bacterial cultures. Put- perspective. After the history and physical ting together the exam is completed and we have valu- of nail disease, merging this with the 161 Abnormalities of the Lunula able clinical information, the physi- medical history and exam, and com- There are three common abnor- cian’s job is to put all the information ing up with a complete diagnostic malities of the lunula. First, there together and make a careful judg- Continued on page 162

Figure 11 A: Nail Presentations of Systemic Disease www.podiatrym.com JUNE/JULY 2015 | PODIATRY MANAGEMENT CME ducation ontinuingE C edical Manifestations of systemic disease Clin Podi- M Nails (from page 161) room in the shoe, especially after put- ting in the foot insert, that the toes are atr Med Surg 21 (2004) 631-640. profile are perhaps among the most not squeezed and there is no undue 6) Richard K. Scher C Ralph Daniel III rewarding things in the practice of pressure on the toes. Nails Diagnosis Therapy Surgery Third Edi- . VII. Identify and remove substanc- tion Elsevier Saunders. 7) Nail Changes in Functional and Or- es, chemicals, cosmetics, soaps, or ganic Arterial Disease Edward A. Edwards IV. Creating the Treatment Plan: socks that are toxic, irritating, or in- M.D. N Engl J Med 1948 239: 362-365. Sep- Don’t Forget About Prevention! flammatory to the skin and nails. tember 2, 1948. VIII. Address the overall dietary 8) Slideshow from Dr. Mark E. Williams The Ten Top Toenail Principles and lifestyle concerns. Diseases of the finger nails University of Vir- After a definitive diagnosis is IX. It is important to engage the ginia School of Medicine. made, a treatment plan can be devised. patient in his or her own care and 9) Common nail changes and disorders I. Be sure to discuss the diagnosis offer the appropriate education, coun- in older people Diagnosis and management or diagnoses, pathology, treatment seling, and coordination of care. Lina Abdullah, RN Ossama Abbas, MD Can plans, indications, risks, benefits, al- X. Hygiene, moisture control, and Fam Physician Feb 2011; 57 (2): 173-181. 10) Chamberlain A. Ng J. Cutaneous ternatives, and costs involved with decreasing fungal load from shoes, melanoma—Atypical variants and presenta- the patient and the family present, if socks, and floor surfaces, ae especially tions. Australian Fam Physician. 2009 Jul; 38 applicable. important in medically or immunolog- (7): 476-482. II. Any underlying medical or vas- ically compromised patients. 11) Ruben BS. Pigmented Lesions of the cular conditions should be addressed, This panoramic approach serves Nail Unit: Clinical and Histopathological Fea- referred out, treated, and controlled, if the patient by not only affording good tures Seminars in Cutaneous Medicine and possible. treatment but much needed preven- Surgery 2010; 29 (3): 148-158. III. The nails, both fingernails and tion as well. 12) Boni E. Elewski Onychomycosis: 162 toenails, should be debrided in length Finally, the practitioner should Pathogenesis, Diagnosis, and Management and thickness. There is an abundance treat the nail problem with the same Clinical Microbiol Rev Jul 1998; 11(3): 415- 429 of evidence that supports periodic de- deference, regard, and concern they 13) Abstract of Study an Assessment bridement of a thickened nail plate would use for any other medical or of the human nail plate pH. Milcovich and as the preferred initial therapy. This surgical problem. G.S. Goriparthi Department of Pharma- should be in addition to excision of The nails, much like the skin, ceutics, School of Pharmacy, University of any ingrown nails, debridement of provide a looking glass into the pa- London. any associated hyperkeratotic tissue, tient’s total health and well-being. 14) Piraccini BM. Tosti A. Drug-induced hypertrophic cuticle, and incision and The information is here for the tak- nail disorders: incidence, management and drainage of any paronychia. ing, as long as the physician can de- prognosis. Drug Safety 1999 Sep; 21 (3): IV. If there’s any bony involve- cipher the code through reconciling 187-201. ment as detected by the imaging stud- the nail pathology with the systemic 15) Seshadri D, De D. Nails in nutrition- al deficiencies. Indian J Dermatol Venereol ies, this has to be addressed. Spur significance of the podiatric clinical Leprol 2012; 78: 237-41. formation can be conservatively or presentation. 16) Julie Jefferson and Phoebe Rich. surgically treated. Osteomyelitis, as This discourse was by no means Review Article Melanonychia diagnosed through imaging studies, exhaustive. A careful observer would Research and Practice Volume 2012 (2012), blood tests, and bone cultures/biop- notice many gaps to be filled. If, how- Article ID 952186, 8 pages. sies, can be treated with excision of ever, the practitioner is motivated to 17) Tosti A. The nail apparatus in colla- the infected bone, and/or the appro- treat nails in a new paradigm, the gen disorders Semin Dermatol 1991 Mar; 10 priate (s). goals of this paper were met. PM (1): 71-6. V. The nails, as well as the skin 18) Holzberg M, Walker HK. Terry’s on the foot and around the nails must nails: revised Definition and new correla- Bibliography tions. Lancet. 1984; 1(8382): 896-9. be treated with the correct oral or top- 1) Zaias, N. The nails in health and 19) Rubin Al, Baran R. Physical signs. ical antibiotic, antifungal and/or top- disease. Norwalk (CT): Appleton & Lange, In: Baran R, de Berker D, Holzberg M, ical skin and nail products that con- 1990. Thomas L(eds). Baran and Dawber’s Dei- dition and moisturize the skin, nails, 2) Baden HP. Diseases of hair and nails. seases of the Nails and their Management, and cuticles, as well as decrease the Chicago: Year Book Medical; 1987. fourth edition, chapter 2, Wiley-Blackwell. fungal and bacterial load and optimize 3) Kosinsky MA, Steward D. Nail changes associated with systemic disease the pH. Often, it is advisable to soak Dr. Rehm is Medical and vascular insufficiency in clinics in po- the foot in a saline or salt-water solu- Director, The Dia- diatric medicine and surgery. Clin Podiatric tion to accomplish maximum skin and betic Foot & Wound Med Surg 1989;2: 302. nail health. Treatment Centers San 4) Fenton DA. Nail Disorders associated Marcos, California. He VI. The biomechanics of the foot with associated with general medical condi- is Board certified by and the areas of abnormal pressure tions. In: Sammon PD, Fenton DA, editors. the American Board of should be addressed with the appro- The nails in disease. London: Heinemann Multiple Specialties in priate orthotic devices and shoes. It is Medical; 1998. P. 102-7. Podiatry. important that there should be ample 5) Abraham J. Herzberg, DPM, Nail

JUNE/JULY 2015 | PODIATRY MANAGEMENT www.podiatrym.com M C edical ontinuing CME EXAMINATION Education

See answer sheet on pagE 165.

1) What conditions do the toe- 6) Antibiotics and retinoids C) Koilonychia nails have in common with the can cause nail disease by the D) Yellow nail syndrome fingernails? following mechanism: A) They reflect the balances A) Interference with 11) Pale nails are due to poor: and imbalances in the body. normal keratinization of the A) hygiene. B) They both are markers matrix B) circulation. for many medical condi- B) Allergic and anaphylactic C) innervation. tions. reactions D) biomechanics. C) They are likely to dis- C) Eosinophilia play the same pathology. D) Septic shock 12) “Half and half” nails are D) All of above. characterized by the following 7) The term onychomadesis features: 2) Besides diseases, the follow- refers to the: A) Proximal half of the ing conditions will commonly A) True transverse nail bluish and distal part manifest in the toenails and leukonychia yellow fingers at the same time: B) Transverse whole thick- B) Oversized lunula with A) Poisoning, medications, ness sulci dividing the nail distal onychomycosis , and in half C) Proximal part white to aging C) Uplifting of the nail plate pink, and distal nail red to 163 B) Athletic injuries, toxic from the nail bed brown cosmetic effects, lack of D) Complete destruction of D) The nail plate resem- hygiene the nail bed epithelium bling the color of café au C) Effects of the sun, carci- lait noma, emotional difficulties 8) Drug-induced paronychia D) Urinary problems, most commonly develops: 13) Subungual melanoma is intestinal flora imbalances, A) After chronic use of the most likely to start out in the dehydration medication. following way: B) After a delayed hypersen- A) A brown spot at the most 3) The most common poisons sitivity reaction. distal part of the nail plate ingested that affect the nails C) Soon after the admin- B) Horizontal white spots involve: istration of the offending with indentations at the A) Phosphorous medication. distal part of the nail plate B) Heavy metals D) In response to shoe C) With a subungual C) Alcohol pressure and subsequent hematoma D) Vinyl chloride ingrown nails. D) As a pigment band visible the length of the 4) Arsenic normally causes the 9) Digital gangrene is common- nail plate nails to develop: ly associated with the following A) Muehrke’s lines medication(s): 14) Up to half of all cases of B) Vertical ridges A) Lamivudine subungual melanoma C) Mees’ lines B) Indinavar A) Are amelanotic and D) Beau’s lines C) Methotrexate can present as a nodule or D) Beta-blockers verruca 5) Common causes of clubbing B) Are extremely painful of the nails include: 10) Malnutrition can be asso- except until the tumor A) Vincristine ciated with the following nail penetrates the underlying B) Cyclophosphamide disorders: bone C) Chronic obstructive A) Nails that are soft and C) Are usually confirmed pulmonary disease thin before biopsy D) Other pulmonary and B) Nails that are triangular D) Will resolve spontaneously cardiovascular disorders in shape Continued on page 164 www.podiatrym.com JUNE/JULY 2015 | PODIATRY MANAGEMENT $ CME EXAMINATION ducation ontinuingE PM’s C edical M CME Program 15) In the case of subungual melanoma, the risk of death is: Welcome to the innovative Continuing Education A) Linked to the color of the tumor. Program brought to you by Podiatry Management B) Proportional to the thickness of the mel- Magazine. Our journal has been approved as a anoma and completeness of excision. sponsor of Continuing Medical Education by the C) Approaching 87% in the best scenario. Council on Podiatric Medical Education. D) Higher in darker skinned persons.

16) Gnawed nails are almost always due to: Now it’s even easier and more convenient to A) Mixed collagen disease. enroll in PM’s CE program! B) Psoriatic arthritis in the distal phalynx of You can now enroll at any time during the year the toes or fingers. and submit eligible exams at any time during your C) Associated with anxiety or obses- enrollment period. sive-compulsive disorder. PM enrollees are entitled to submit ten exams D) Amyloidosis. published during their consecutive, twelve–month enrollment period. Your enrollment period begins 17) The following information can be ascer- tained from examining the nails: with the month payment is received. For example, A) The age of the patient if your payment is received on November 1, 2014, 164 B) The intelligence of the person your enrollment is valid through October 31, 2015. C) Racial heritage If you’re not enrolled, you may also submit any D) Inner emotional state exam(s) published in PM magazine within the past twelve months. CME articles and examination 18) When examining the nails, the most im- questions from past issues of Podiatry Manage- portant findings relate to: ment can be found on the Internet at http:// A) Abnormalities of the nail surface and www.podiatrym.com/cme. Each lesson is ap- texture. B) The amount of subungual debris. proved for 1.5 hours continuing education contact C) The amount of hypertrophy of the nail hours. Please read the testing, grading and payment bed. instructions to decide which method of participa- D) How often the nails are debrided. tion is best for you. Please call (631) 563-1604 if you have any ques- 19) A normal nail will have the following tions. A personal operator will be happy to assist you. characteristic(s): Each of the 10 lessons will count as 1.5 credits; A) An extremely small or absent lunula thus a maximum of 15 CME credits may be earned B) A soft and flexible free edge C) A white nail plate during any 12-month period. You may select any 10 D) Nail growth rate of 18 months from in a 24-month period. cuticle to free edge The Podiatry Management Magazine CME 20) A successful treatment program for dis- program is approved by the Council on Podiatric eased nails should include the following: Education in all states where credits in instructional A) Addressing or ruling out underlying media are accepted. This article is approved for medical or vascular conditions 1.5 Continuing Education Contact Hours (or 0.15 B) Education, counseling, and discussion of care with the patient CEU’s) for each examination successfully completed. C) Proper debridement in length and thickness D) All of the above Home Study CME credits now See answer sheet on page 165. accepted in PennsylvaniaContinued on page 164

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Enrollment/Testing Information Education 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 165 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.

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EXAM #4/15 Nails—They Mean More Than You Think!—Part 2 (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 166 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 : ______

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