Review Article

Review Article Nail changes and disorders among the elderly Gurcharan Singh, Nayeem Sadath Haneef, Uday A Department of Dermatology and STD, Sri Devaraj Urs Medical College, Tamaka, Kolar. India Address for correspondence: Dr. Gurcharan Singh, 108 A, Jal Vayu Vihar, Kammanhalli, Bangalore-560043, India. E-mail: [email protected] ABSTRACT Nail disorders are frequent among the geriatric population. This is due in part to the impaired circulation and in particular, susceptibility of the senile nail to fungal infections, faulty biomechanics, neoplasms, concurrent dermatological or systemic diseases, and related treatments. With aging, the rate of growth, color, contour, surface, thickness, chemical composition and histology of the nail unit change. Age associated disorders include brittle nails, trachyonychia, onychauxis, pachyonychia, onychogryphosis, onychophosis, onychoclavus, onychocryptosis, onycholysis, infections, infestations, splinter hemorrhages, subungual hematoma, subungual exostosis and malignancies. Awareness of the symptoms, signs and treatment options for these changes and disorders will enable us to assess and manage the conditions involving the nails of this large and growing segment of the population in a better way. Key Words: Nail changes, Nail disorders, Geriatric INTRODUCTION from impaired peripheral circulation, commonly due to arteriosclerosis.[2] Though nail plate is an efficient Nail disorders comprise approximately 10% of all sunscreen,[3,4] UV radiation may play a role in such dermatological conditions and affect a high percentage changes. Trauma, faulty biomechanics, infections, of the elderly.[1] Various changes and disorders are seen concurrent dermatological or systemic diseases and in the aging nail, many of which are extremely painful, their treatments are also contributory factors.[5,6] The affecting stability, ambulation and other functions. The following changes are observed in human nails as part prevention and management of these conditions require of the aging process: periodic cutting of the nails and appropriate medical care. Unfortunately, these are difficult for the elderly a) Alteration in chemical composition because of thickness of the nails, difficulty in accessing The calcium and iron contents of the aging nails are the feet, poor vision and sometimes, lack of motivation increased and decreased respectively.[2] for personal care. This article reviews the age associated b) Alteration in histology nail changes and disorders along with related The nail plate keratinocytes are increased in size, with management. increased number of ‘pertinax bodies,’ which are remnants of keratinocyte nuclei. The nail bed dermis SENILE CHANGES IN NAILS shows thickening of the blood vessels and degeneration of the elastic tissue, especially beneath the pink part The senile changes in the nails are thought to result of the nail.[7] How to cite this article: Singh G, Haneef NS, Uday A. Nail changes and disorders among the elderly. Indian J Dermatol Venereol Leprol 2005;71:386-92. Received: July, 2004. Accepted: December, 2004. Source of Support: Nil. Conflict of interest: None declared. Indian J Dermatol Venereol Leprol Nov-Dec 2005 Vol 71 Issue 6 386 Singh G, et al: Nail changes and disorders among the elderly c) Alteration in nail growth ice-cream, i.e. a proximal white portion with absent Fingernails and toenails grow at an average rate of 0.1 lunula, a central normal pink band and an opaque mm/day (3.0 mm/month) and 0.03 mm/day (1.0 mm/ distal free edge.[14] month) respectively.[7] In the elderly, the rate of nail growth decreases by approximately 0.5%/year between e) Alteration in contour 25 to 100 years of age.[8] Senile nails usually have an increased transverse curvature and a decreased longitudinal curvature. As observed by Oreintreich and Scharp (1967),[2] Flattening of the nail plate (platyonychia), spooning thumbnail growth decreases on an average by 38% (koilonychia), and pincer nail deformity (involution), between the third and the ninth decade. In this study, are found more frequently.[8,15] the decrease in growth of nails in females was greater up to the sixth decade; thereafter no change was f) Alteration in surface texture observed till the eighth decade, whereas in males, the Normally, the nails have a smooth surface. The senile slowing was more pronounced from the sixth to the nail may have increased longitudinal striations due to eighth decade.[2] altered turnover rate of the matrix cells. The striations are termed “onychorrhexis” if they are superficial and d) Alteration in nail color “ridges” or “sausage-link ridges” or “beading” if Senile nails may appear pale, dull, and opaque, with deep.[7,8] Aging is the commonest cause of the color ranging from white (leuconychia) or yellow onychorrhexis.[10] Beau’s lines (transverse ridges) and to brown or grey.[7] Leuconychia may be true (due to pitting are also found frequently.[16] The nails may be matrix involvement), which may be total, subtotal, rough (trachyonychia) with splitting and fissuring. transverse, punctate or longitudinal; pseudoleu- conychia (of exogenous origin), seen in onychomycosis, g) Alteration in thickness and keratin granulations after nail enamel application; Fingernails have a normal average thickness of 0.6 mm and apparent leuconychia (due to changes in the in males and 0.5 mm in females. Toenails are thicker, underlying tissue). 1.65 ±0.43 mm and 1.38±0.2 mm in males and females respectively.[17] The nail plates of the thumb and great The clinical presentations are varied like toe are the thickest, whereas the little finger has the i) Terry’s nails: The nails are colored white proximally thinnest nail plate. In the elderly, the nail plate thickness and have a distal normal pink band of 0.5-3 mm may increase, decrease or may remain unchanged.[7,8] width. These are seen in seen in cirrhosis of the liver, chronic congestive heart failure, adult-onset NAIL DISORDERS AMONG THE ELDERLY diabetes mellitus and malnutrition. ii) Half and half nails of Lindsay: Seen in uremic a) Brittle nails (Fragilitas unguium) patients, the nails have a proximal dull white area The nail plate hardness is dependent on its state of with the distal 20-60% portion brownish.[9] hydration, the normal water content being 18% (10- iii) Muehrcke’s paired, narrow white bands: The bands are 30%). Nails become brittle when the water content is present parallel to the lunula. This is seen in less than 16% and become soft when it is above 25%.[7] hypoalbuminemia (less than 2.2g/100ml),[10] In persons older than 60 years, brittle nails are common, nephrotic syndrome, glomerulonephritis, manifesting as excessive longitudinal ridges, roughness malnutrition, acrodermatitis enteropathica[10] or of the nail plate (trachyonychia), horizontal lamellar following chemotherapy.[11] splitting of the distal nail plate (onychoschizia), and/or iv) The lunula may be decreased or absent irregularity of the distal edge of the nail plate (Castle altogether.[12,13] battlement appearance).[5,18,19] v) Neapolitan nails, which can be seen in up to 20% of the persons older than 70 years, are characterized Repeated cycles of hydration and dehydration, as occur by three bands similar to the colors of Neapolitan in excessive domestic wet work or overuse of 387 Indian J Dermatol Venereol Leprol Nov-Dec 2005 Vol 71 Issue 6 Singh G, et al: Nail changes and disorders among the elderly dehydrating agents like nail enamels, nail enamel incompatibility can cause faulty biomechanics leading removers and cuticle removers, may precipitate brittle to onychodystrophies such as nail plate hypertrophy nails.[5,18,20] The first three fingers of the dominant hand (onychauxis), subungual corn (onychoclavus), ingrowing are particularly susceptible.[18] toe nails (onychocryptosis), onychogryphosis, onycholysis, subungual hematoma and subungual After elimination of the exacerbating factors, local hyperkeratosis.[5,7] measures should be undertaken to re-hydrate the nail plate, cuticle and the nail folds. This can be achieved Treatment should address the underlying bony by soaking the nails in lukewarm water for 10 to 20 deformity, foot care and appropriate footwear. Velcro minutes, followed by application of moisturizers such shoes are convenient for the elderly. A molded shoe or as lactic acid, urea, phospholipids or mineral oils, an orthotic insert helps in non-surgical management of preferably under occlusion (cotton gloves or socks).[5] bony deformities.[5,7] Oral biotin, iron, thiamine, cysteine, pantothenic acid, PABA, have been found to be effective.[6,21,22] In d) Infections/Infestations intractable cases, formaldehyde containing nail enamels The nail apparatus may get primarily infected or involved can be helpful, which should be removed and reapplied in infections of the adjacent structures. not more than once a week.[5] Generally, onychomycosis is the commonest nail b) Clubbing (Hippocratic nails/watch glass nails) infection, accounting for 40% of all onychopathies and Digital clubbing is said to be present if the angle 30% of all cutaneous fungal infections.[24] The prevalence between the normal nail plate and the skin of the finger of onychomycosis increases with age, reaching nearly at the proximal nail fold (Lovibond’s angle) is less than 20% in patients over 60 years.[25] It is especially common 180°, usually close to 160°.[23] in the elderly, often involving both toenails and fingernails. The great toenail is the commonest one Bilateral clubbing occurs generally (80%) due

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