DISEASES OF THE NAILS
The nails of the hands and feet are subject to various diseases. The
chief of these are:
Onychocryptosis, or ingrown nail.
Onychophosis, or calloused nail groove.
Onychia, or inflammation of the matrix.
Paronychia, or inflammation around the nail.
Onychauxis, or club nail.
Onychatrophia, or atrophy of the nail.
Onychoptosis, or falling off of the nail.
Onychorrhexis, or brittle nail.
Some of these diseases of the nails are the result of a general
systemic disturbance, but only the local treatment of such conditions
becomes the province of the podiatrist. It is often necessary to
distinguish between a local chiropodical condition and a local
manifestation of some serious systemic disease; it is then necessary
for the medical practitioner and the podiatrist to join hands in making
a diagnosis for the proper guidance of both practitioners.
=Onychocryptosis=, or ingrown toe nail, is a common affliction of the
nail, and is thoroughly described in a separate chapter.
=Derivation.= From the Greek, onyx, nail, and krypto, I hide or conceal.
=Onychophosis=, or calloused nail groove, is also one of the common
types of nail lesions, and is discussed separately. This lesion
is often mistaken for ingrown toe nail, and treatment, improperly
directed, often causes bad results.
=Onychia or Onychitis= is an inflammation of the matrix with
suppuration and final shedding of the nail.
=Derivation.= From the Greek, onyx, nail, and itis, inflammation.
=Etiology.= Onychia may be due to trauma, causing malformation of the
nail, and subsequent inflammation, but is most usually due to bacterial
infection. Removal of ingrown toe nails under septic conditions, or
the entrance of bacteria through self-inflicted or other wounds offer
opportunities for infective processes on a part of the body none
too clean at best. Syphilis, tuberculosis and eczema are also often
etiologic factors.
=Pathology.= Bacterial infection or trauma causes the nail matrix
to become inflamed, with the accompanying pathologic changes that
occur in all inflammatory processes. There is a gradual solution of
the continuity between the nail proper and the matrix, and as the
degenerative processes continue, namely the formation of pus and the
solution of the tissues which comprise the matrix, the grooves in the
nail matrix, which hold the corresponding ridges of the nail, are lost
and the mechanical union of the two parts cease. The nail subsequently
falls off. If the entire matrix has been destroyed, no new nail will
grow, but this does not usually occur. Malformation of the new nail is
quite common, due to partial destruction of the matrix.
=Diagnosis.= The matrix of the nail is inflamed and severe pain is felt
when pressure is brought to bear on the nail plate. The nail bed and
the nail grooves are often involved and the inflammation may continue
to such an extent as to involve lymphatics and cause destruction of a
large area of tissue.
Pus forms at the root of the nail, and the nail itself gradually
becomes loosened from its bed. In cases due to injury or local
infection, one or two toes may be involved, but when the cause is of
systemic origin, all of the nails, including those of the hand, may
become infected.
=Treatment.= The treatment of simple onychia consists in protecting
the part from further injury and irritation and it often becomes
necessary to cut the shoe to accomplish this. In severer cases, shoes
should not be worn until resolution commences.
Wet dressings are valuable, Burow’s solution or boric acid solution
being all that is necessary in mild cases.
When pus manifests itself, it is necessary to remove the nail over the
abscess and to establish free drainage. Wet dressings of bichloride
of mercury (¹⁄₅₀₀₀) for 48 hours may be used, and when drainage is
complete, the cavity may be swabbed with silver nitrate, 5 to 10%. Dry
dressings of thymol iodide or boric acid powder will usually suffice to
complete a cure.
The parts should be packed with sterile gauze so as to keep the soft
tissues separated from the nail and to prevent irritation and pressure.
This packing should not be too tight otherwise pus absorption with
subsequent infection, is likely to occur.
In extreme cases, in which the surrounding tissues are involved and
destruction has gone on to a greater extent, the entire nail must be
removed, and the matrix destroyed by caustics or by curettage.
=Paronychia, or Paronychitis=, is an inflammation of the tissues around
the nail, and may involve all the tissues of the distal phalanx,
including the bone.
=Synonyms.= Felon, panaris, whitlow.
=Derivation.= From the Greek, para, beside, and onyx, nail.
=Etiology.= Paronychia is usually caused by local bacterial infection,
due to treating the nail grooves with unclean instruments, or it may be
of systemic origin. It is often associated with onychia and in these
cases is due to a spreading of the inflammation of the matrix to the
surrounding tissues. Pressure of an ill-fitting shoe or stocking or of
a foreign body may be a cause, and ingrowing toe nail may later develop
into a paronychia. Syphilis often causes this lesion.
=Pathology.= The pathology of paronychia is much the same as that of
onychia. The tissues surrounding the nail become inflamed, either by
bacterial infection or by trauma, and all the signs and symptoms of
inflammation manifest themselves. Swelling is marked and pus may or may
not be present. Tissue destruction continues unless proper treatment is
given, and the bone is often involved, causing periostitis or osteitis.
=Diagnosis.= Simple paronychia may exist without any hypertrophy
of the nail itself, and may be due to pressure of a shoe or to a
chronic ingrowing toe nail. The great toe is most commonly affected.
The inflammation may be only slight and superficial, or it may be
quite severe with great pain and swelling, terminating in a general
intercellular infection with suppuration. Nourishment is interfered
with and the nail may be shed much the same as in onychia. Pain is of a
throbbing type which is immediately relieved when the abscess cavity is
opened and the pus drained.
=Treatment.= Like onychia, paronychia should be treated with wet
dressings and stimulating medications. In cases in which there is no
suppuration, the following ointment will give good results:
℞ Acidi salicylici grs. X
Ung. hydrarg. amm. Oz. 1
M. ft. ung. Sig. Keep on affected part constantly.
The corners and lateral edges of the nail should be separated from the
soft tissues by means of sterile gauze, or they may be removed. Pus
should be drained, with the assistance of antiseptic wet dressings such
as bichloride of mercury, ¹⁄₅₀₀₀, and if excessive granulations are
present, they should be snipped off or destroyed with silver nitrate.
If necessary, free incisions should be made, which will relieve the
pain as well as assist in draining the pus.
In chronic paronychia it often becomes necessary to remove the entire
nail, including the root, and under local anesthesia, this is easily
accomplished. Rest is essential in these cases, and after suppuration
has ceased, stimulants such as balsam of Peru or ichthyol may be used
to good advantage.
In cases of paronychia, due to syphilis, it must be remembered that
the treatment must be constitutional as well as local and the family
physician of the patient should attend to the former feature of the
treatment. Mercurial ointments, applied twice daily, are usually
employed locally.
[Illustration: ONYCHOGRYPHOSIS]
=Onychauxis=, or hypertrophy of the nail, is an overgrowth or
enlargement of the nails of the fingers and toes. When the hypertrophy
is accompanied by deformity, the condition is called onychogryphosis.
=Derivation.= From the Greek, onyx, nail, and auxe, increase.
=Etiology.= Enlargement of the nail is a result of hyperplasia of the
papillæ of the matrix, the thickening occurring at the base, front,
lateral edges or over the entire area of the nail depending on the part
diseased.
Pressure is no doubt a causative factor, and lack of care of the nails
will also cause a thickening. Injury to the matrix will cause the nail
to become hypertrophied, producing in most cases a true club nail
(onychogryphosis).
Chronic cutaneous lesions, such as eczema or psoriasis and other
diseases such as syphilis, gout and rheumatism, and nervous diseases
or injury to the nerves supplying the nails, may act as causes for
onychauxis.
=Pathology.= Pressure or injury causes a widening of the nail fold
which allows the formation of a thicker nail. The nail bed is irritated
at the same time and a horny mass forms on it below the nail, which
acts as a barrier to the forward movement of the nail cells, and by
raising them up, determines more or less, the degree of deformity. The
papillæ of the matrix become enlarged, and may be seen protruding above
the normal structure, when the nail is removed.
The thickened and deformed nail thus produced, is often the cause of
other nail lesions, due to its pressure on the soft tissues. Bacterial
infection is also common at this point, due to the fact that the mass
of epithelial cells is a good breeding place for microorganisms.
=Diagnosis.= Onychauxis may be congenital or acquired, usually the
latter. Simple hypertrophy of the nail is rarely found, but overgrowth
with deformity is quite common. The nail becomes hardened, due to a
closer cohesion of its component cells; its transparency is lost, and
it assumes a dirty brown or even black color. The surface becomes
rough, due to the presence of longitudinal and wavy transverse ridges.
One or all of the nails may be affected; there may be a simple
thickening or there may be a lateral overgrowth, which may result in
paronychia. The inflammation may be slight or it may be severe and
purulent. The nail, as it continues to become thickened, may assume
various shapes resembling claws, talons, horns, etc. The big toe
nail is the one most usually affected and often only the one foot is
involved. This is indicative of a traumatic etiology.
Tuberculosis patients have a moderate onychauxis in most cases,
particularly on the nails of the fingers, while hypertrophy is often
seen in the inflammatory lesions such as eczema, psoriasis, etc.
Older persons are more liable to be affected with hypertrophy of the
nail than younger persons, as there is a natural tendency to epithelial
overgrowth in the aged.
[Illustration: ONYCHAUXIS]
=Treatment.= To affect a cure in case of hypertrophy of the nails it
is necessary to recognize the cause. Thus, in cases of onychauxis,
in which the general systemic condition is at fault, treatment must
be directed by the family physician along constitutional lines and
includes the taking of tonics, arsenic, mercury, etc. If a cutaneous
lesion is the etiologic factor, it becomes necessary to treat the
case both generally and locally. If the cause be an external one
alone, local treatment is sufficient. For these latter conditions, the
treatment is divided into palliative and radical procedures.
The _palliative_ treatment consists in keeping the nail properly cut.
For this purpose, the rotary file, or surgical drill, as it is called,
is very efficient. Suitable burrs are used, and care is taken that the
skin of the nail grooves is not injured. Infections are easily caused
through the careless use of this instrument. After the nail has been
thinned and is as nearly like a normal nail as is possible, the part
should be cleansed with alcohol, and tincture of iodine (4%) should be
applied. The grooves may be packed with sterile cotton and covered with
collodion (cocoon dressing) which will avoid any tenderness that may
be felt after the nail has been cut down. The hard nails may also be
softened by the application of sodium sulphide or liquor potassae and
when softened, may be scraped away.
If thickened or club nails become very painful, it is often necessary
to resort to _radical_ measures, as this is the only permanent cure
for this trouble. The entire nail must be completely removed under
local anesthesia, and subsequently the entire nail matrix should
be thoroughly scraped away by means of a sharp curette. The wound
thus produced is kept in sterile dressings and is allowed to heal
by granulation. It is quite common to find only a small area of the
matrix that is vital, particularly in chronic cases of club nail, so
that curettage is really a simple procedure. A complete cure should be
effected in from two to three weeks, the patient being able to walk
with a cut-out shoe two or three days after the operation.
=Onychatrophia=, or atrophy of the nails, is a condition in which the
nails of the toes and fingers become smaller and often are shed from
the grooves in which they are contained.
=Derivation.= From the Greek, onyx, nail, and atrophia, atrophy.
=Etiology.= Atrophy of the nails may be caused by any one of many
factors, among which are the inflammatory skin diseases, nervous
diseases, constitutional disorders and injuries.
Injury to the nail matrix causes complete or partial cutting off of
nourishment. If the nourishment is completely cut off, the nail matrix
will disintegrate and cause the nail to be shed. New nails usually
grow in these cases. If the injury is less severe, there is only a
temporary arrest in the nail growth, and the nail becomes thin and
small discolorations are seen in the nail substance.
Inflammation of the soft tissues around the nail which is accompanied
by suppuration, may cause atrophy and shedding of the nail. The nail
will grow again as a rule, but often when the etiology is systemic, the
new nails shed as soon as they are formed (onychia maligna).
In nervous diseases, such as cerebral paralysis, tabes dorsalis,
syringomyelia, leprosy, division of the nerves, etc., from the
vasomotor disturbances due to the nerve lesion, a bleeding may occur
about the posterior nail fold, and atrophy of the nail may result. The
nails, as a rule, usually grow again.
In stasis of the blood stream in the extremities due to heart lesions,
in venous congestion from emphysema, or in any lesion in which the
circulation is impaired, the nails may undergo atrophy, particularly
the nails of the fingers.
Diseases causing scarring of the nail matrix, such as pustular
syphilides, gummata and variola, give rise to a partial destruction
of the matrix and a shedding of the nail. Subsequent scarring may
completely destroy the matrix, so that no new nail can grow.
In systemic diseases that cause wasting of the tissues, such as chronic
tuberculosis, nephritis and diabetes mellitus, the matrix is usually
under-nourished and the nails become discolored, soft and brittle, and
often crumble.
Chemical poisons, such as arsenic, silver and lead, may cause atrophy
of the nails. Those who work with chemicals and are compelled to put
their fingers in acids and in alkalies often develop brittle, opaque
nails. In general toxemias, the affliction of the nail is caused by
interference with the nail nourishment at the matrix.
=Pathology.= When the nourishment of the matrix has been interfered
with, the cells do not develop as rapidly as they should, and the nail
becomes thin and streaked. The lustre is lost and the nails become gray
or yellow, and often also become brittle. If the grooves in the nail
bed are destroyed, the mechanical attachment between it and the nail is
lost and the nail is cast off. Infective processes cause complete or
partial destruction of the matrix by solution, and this in turn causes
complete or partial loss of nail. White spots (leuconychia), said to
be due to the entrance of air under the nails, are often seen, and
gradually move toward the distal end of the nail.
=Diagnosis.= Atrophy of the nails may be congenital or acquired, the
former being rare and usually accompanied by imperfect development of
the phalanges and scantiness of the hair throughout the body (alopecia
universalis). Acquired atrophy in some form is the usual condition.
The nails present various appearances. They may be thin, soft,
brittle, lustreless or opaque, split very easily, may be streaked or
even worm-eaten in appearance. One or all of these conditions may
be present. Thinning and splitting of the free ends may accompany
systemic diseases, and some chronic inflammatory (especially scaly)
skin lesions. Some nails are thinned at the ends with a central fissure
extending toward the root. Transverse thinning or furrows are met
with in fevers. The nails are always affected when nutrition has been
lowered, due to depression of the general health.
In wasting diseases, such as chronic tuberculosis, diabetes, etc., the
spoon-nail is observed. This is a condition in which the lateral and
free margins are raised, leaving a spoon-like depression in the centre.
Trauma, parasites, lowered nutrition and nervous diseases cause a
crumbly, brittle nail. This is fairly common, and may be limited to one
or more nails of the toes and fingers or it may be general. The atrophy
may begin at either end, and extend forward or backward.
=Treatment.= Treatment of a local nature is worthless if the cause
be systemic. Much like hypertrophy, the cure of atrophy depends on
an exact determination of the etiology. Systemic treatment along
proper lines will usually effect a cure. Local treatment consists in
protecting the nails from irritation and sometimes even from water.
The nails should be cut even and smooth and mollifying ointments
and lotions are advisable. Cocoon dressings are very efficient
for affording protection. In atrophy, due to local circulatory
interference, balsam of Peru (50%), in castor oil, or even pure, will
stimulate nail growth. This should be applied once a day and can be
retained by cocoon dressing. As a soothing agent the following may be
employed.
℞ Acid. boric.
Bismuth. subnitratis aa 0.60
Ung. aquae rosae
Unc. zinci oxidi aa 16.00
M. Ft. ung. Sig. Apply to the nails morning and night.
=Onychoptosis=, falling off of the nail, and =Onychorrhexis=, brittle
nail, are atrophies and have been discussed as such in the preceding
sub-head.