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49 Onycholysis
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199
Fig. 49.11 Onycholysis observed in the big toenails
Figs. 49.8–49.10 Further progressed onycholysis
For treatment, it is necessary to completely avoid further
trauma and chemical irritants, and the nail bed should be
kept dry. The affected nail area should be cut off, and exposing and drying the nail bed is very helpful in removing
Fig. 49.12 Onycholysis observed in psoriasis
Pseudomonas and reducing Candida. If it occurs secondarily, improvement is seen when the underlying disease is
treated, but it often occurs idiopathically, and topical application of steroids and retinoids is known as a treatment
method, but there are many cases that do not respond well,
making it one of the difcult diseases to cure. For the treatment of onychodystrophy including onycholysis, triamcinolone intralesional injection, steroid ointment or calcipotriol
ointment, retinoid ointment or tacrolimus cream topical
application, oral administration of retinoids or cyclosporine
or steroids, and photodynamic therapy have been used.
Topical steroids have the advantage of being painless during
treatment and not having to visit the hospital frequently, and
relatively good effects, but they have the disadvantage that
they can cause skin atrophy, dilated blood vessels, and rarely,
weakening of bones in the absorbed area due to high potency
and long-term use. Calcipotriol ointment has almost no side
effects, but its effect is low when used alone, so it is almost
always used with steroid ointment.
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49 Onycholysis
Triamcinolone intralesional injection has the advantage
of being easy to treat once every 2–6weeks depending on the
literature and having a good treatment effect. Unlike steroid
ointments, side effects such as skin atrophy and vasodilation
are rare, but side effects such as pain, hematoma, and infection have been reported during injection, so caution is
required. In Korea, for 69 nails with onycholysis (62 ngernails, 7 toenails), the rst 2 times were at intervals of 2weeks
at a concentration of 2.5 mg/mL, and then once every
Figs. 49.13 and 49.14 This is the oil drop sign that appears in psoriasis, and if it occurs close to the hyponychium, it can progress to
onycholysis
Figs. 49.16 and 49.17 Onycholysis observed in chronic hand eczema
Fig. 49.15 Onycholysis observed in a farmer’s hand
49 Onycholysis
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Fig. 49.18 Onycholysis misdiagnosed as toenail onychomycosis
201
4 weeks at a concentration of 5.0 mg/mL for a total of 7
times up to 20weeks. Triamcinolone suspension was injected
close to the nail with a dermojet at both ends of the proximal
nail fold, and the nails that showed very excellent treatment
effects were reported to be 37.6% in doctor’s evaluation
(patient evaluation 37.6%), excellent treatment effects were
46.4% in doctor’s evaluation (patient evaluation 42.0%),
ordinary treatment effects were 14.5% in doctor’s evaluation
(patient evaluation 1.4%), and poor treatment effects were
1.4% in doctor’s evaluation (patient evaluation 18.8%). Most
patients reported pain immediately after treatment. Although
appeals were made, no patient experienced pain for more
than a day, and there were no signs of hematoma or infection.
There were also no signs of atrophy or hypochromia.
Recently, there have been reports of studies treating onychomycosis and onychodystrophy with a 1064nm long-pulsed
Nd:YAG laser. The application of this laser has been reported
in Korea as a safe and effective treatment for onycholysis. It
is thought that this laser stimulates the nail bed and nail
matrix, promoting the growth of normal tissue, normalizing
the nail bed, and growing the ventral nail plate into a hard
keratin with adhesive force, showing a healing effect. During
laser irradiation, patients reported feeling a slight heat sensation, but no other side effects were reported. I rst prescribed
an ointment that is evaluated to be effective for M, advised
not to stimulate the nails, and decided to observe regularly in
the future.
Fig. 49.19 Green nail caused by the proliferation of Pseudomonas in
onycholysis
Longitudinal Ridges
∗∗∗
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50
I don’t think it’s happened before, but I have a lot of vertical, parallel lines on my thumbnail. What kind of disease is this? Is it because I have a bad stomach or
something? (Fig.50.1).
Mr. J, a 55-year-old man, came into the clinic and immediately showed his thumbnail, saying, “One day, I looked at
the surface of my nail and there were many long lines parallel from the root to the end of the nail. What kind of disease
is this? Is it because my internal organs are bad?”
Longitudinal ridging refers to one or several vertically
extending straight ridges connected from the proximal end of
the nail plate to the distal end that occur in parallel at regular
intervals on the surface of the nail plate. The ridges may be
interrupted regularly, showing a bead or sausage shape.
Multiple thin ridges can occur, and as a kind of physiological
phenomenon, they become more pronounced with age, so
they are mainly found in the elderly, but sometimes they can
appear in young people and rarely in children. As age
increases, the number of ridges tends to increase, and their
outlines tend to become clearer. It mainly occurs on the
thumbnail but can also be seen in other nails. Sometimes a
wide, longitudinal median ridge has the appearance in cross
section of a circumex accent, which usually appears after
trauma but can also be inherited. Longitudinal ridges may
occur after damage to the proximal part of the nail, due to
genetic diseases such as Darier’s disease, or when there is a
tumor such as a glomus tumor on the nail bed (Figs.50.2,
50.3, 50.4, 50.5, 50.6, 50.7, 50.8, 50.9, 50.10 and 50.11).
So far, no effective treatment for Longitudinal ridges has
been reported, and it is only a cosmetic issue. I told Mr. J not
to worry as it was not a pathological phenomenon, and when
I showed him that the same thing happened to my ngernails, he felt reassured and left the examination room.
Fig. 50.1 Longitudinal ridges on nails found on the thumbnail
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_50
Fig. 50.2 Longitudinal ridges mainly occur on the thumbnail but can
also be seen on other nails
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Fig. 50.3 Cases where the ridges are regularly disconnected, showing
a bead or sausage shape—10× magnication
50 Longitudinal Ridges
Fig. 50.4 Bead or sausage-shaped longitudinal ridges—30× magnication photo
Figs. 50.6 and 50.7 Longitudinal ridges observed on women’s ngernails
Fig. 50.5 Longitudinal ridges observed on toenails
50 Longitudinal Ridges
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Fig. 50.8 Longitudinal ridges and onycholysis observed on a child’s
little nger
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Fig. 50.9 Longitudinal ridges and onychorrhexis observed on the nails
of a patient with Darier’s disease
Figs. 50.10 and 50.11 Onychorrhexis and longitudinal ridges
Onychodystrophy, Twenty-Nail
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Dystrophy
51
I don’t know when, but all 20 of my nails have become
thick and ugly. Why is this happening? (Figs. 51.1 and
51.2).
A woman in her 40s, P, came for a checkup because she
wanted to know the name of the disease that was causing her
nails to become strangely thick and deformed. “Why are my
nails changing like this? Is there something wrong with my
body?” she asked.
Nail disorders account for about 10% of all skin diseases
and can cause pain, functional problems, and cosmetic
issues. These nail disorders can show various clinical ndings in one disease, and conversely, the same nail changes
can occur due to different diseases, making diagnosis and
classication difcult. They can be classied according to
the cause, such as genetics, secondary changes due to systemic diseases, infectious diseases, nail deformities due to
other skin diseases, trauma, etc., and according to the shape
of the nail lesion itself. Among nail diseases, onychodystrophy is a general term for morphological changes in the nail
and refers to nail diseases excluding trauma, tumor, and onychomycosis. Known causes of nail dystrophy include psoriasis, lichen planus, alopecia areata, lichen striatus, and hand
eczema, but it is most often idiopathic, occurring without a
specic cause. Depending on the morphological deformation
of the nail, onychodystrophy can include Beau’s line, trachyonychia, pitting nail, longitudinal ridge, median nail dystrophy, leukonychia, spoon nail, onychomadesis, onycholysis,
subungual hyperkeratosis, and washboard nail. These nail
changes can be divided according to the affected area and
range, time, and intensity. For example, trachyonychia
appears after long-term moderate damage over a wide range
of the nail matrix, while pitting nails can be observed when
moderate damage to the nail matrix occurs over a short
period. Other conditions such as longitudinal ridge, median
nail dystrophy, leukonychia, and washboard nail also appear
due to damage to the nail matrix. In particular, trachyonychia
is a nail change where the surface of the nail plate becomes
rough and many thin longitudinal ridges appear due to longterm damage to the nail matrix, and when all 20 nails are
affected, it is called twenty-nail dystrophy. Twenty-nail dystrophy is a relatively rare nail disorder characterized by loss
of luster, discoloration, easy breakage of all nails, and the
appearance of longitudinal ridges. Since Hazelrigg etal. rst
described twenty-nail dystrophy in children in 1977,
Samman divided it into cases accompanying skin diseases
such as alopecia areata, psoriasis, and lichen planus and
Figs. 51.1 and 51.2 Twenty-nail dystrophy (pachyonychia)
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_51
207
208
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51 Onychodystrophy, Twenty-Nail Dystrophy
cases occurring idiopathically. Among these, idiopathic
cases were further classied into twenty-nail dystrophy in
children and severe onychodystrophy that mainly occurs in
adults. Additionally, Commens broadly classied it into congenital and acquired. Congenital factors included familial
and sporadic twenty-nail dystrophy, nail-patella syndrome,
pachyonychia congenita, and hidrotic ectodermal dysplasia,
and acquired cases were almost similar to the skin diseases
suggested by Samman. Twenty-nail dystrophy appears clinically in ve types: pitting type, sandpaper (shallow ssure)
type, ssure (deep ssure) type, hypertrophic type, and atrophic type. Hypertrophic type and atrophic type usually
appear in combination with the basic three types, so they are
sometimes classied into only three types. Histopathological
examination of the nail matrix most often shows spongiform
inammation, and other ndings similar to psoriasis or
lichen planus may be seen. Onychodystrophy is clinically
simple, so the same or similar changes can be caused by various causes, and various lesions can appear due to one cause,
making diagnosis difcult. If it is difcult to diagnose by
visual inspection, cutting the nails and conrming the histopathologic ndings can help in diagnosis, and onychomycosis or tumors can be ruled out (Figs.51.3, 51.4, 51.5, 51.6,
51.7–51.9).
Onychodystrophy are being attempted with various treat-
ment methods such as topical steroids, tretinoin, calcipotriol
and tacrolimus application, steroid intralesional injection,
cyclosporine or steroid oral administration, surgery, cryotherapy, PUVA, long-pulsed Nd:YAG laser treatment, etc.
However, despite various treatment methods, the nails them-
selves grow slowly at 3mm per month for ngernails and
1 mm or less for toenails, and unlike general tissues, the
absorption and delivery of drugs are slow, so many nail diseases collectively referred to as onychodystrophy have a
slow treatment response and a long treatment period, making
it difcult to judge the treatment effect. Also, despite various
treatment methods, the side effects are large compared to the
treatment effect, so currently only steroids or calcipotriol,
tacrolimus topical application, triamcinolone intralesional
injection, etc. are mainly used. Steroid ointment application
is effective but can cause side effects such as skin atrophy
and nail loss if used for a long time, and calcipotriol is safe
but has a small treatment effect, so it has the disadvantage of
having to be used in combination with other treatments. In
Korea, there have been reports of improvement in washboard
nails with tacrolimus topical application, and although the
mechanism of action is not clear, it is thought to be related to
the anti-inammatory effect as the inammatory process is
an important factor in causing onychodystrophy.
Triamcinolone intralesional injection is known to be relatively safe with less systemic side effects compared to other
treatments and has a good effect. Also, the laser action mechanism of 1064nm long-pulsed Nd:YAG laser on onychodystrophy is thought to stimulate the nail matrix and nail bed by
thermal energy, promoting the growth of normal nail plates.
I explained to Ms. P the treatment process and treatment
method for onychodystrophy and told her that this treatment
takes time and requires persistence, so let’s work together to
achieve good results.
Figs. 51.3 and 51.4 Twenty-nail dystrophy (pitting type)
51 Onychodystrophy, Twenty-Nail Dystrophy
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Figs. 51.5 and 51.6 Twenty-nail dystrophy (sandpaper type)
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Figs. 51.7–51.9 Twenty-nail dystrophy (ssure type)
Onychoschizia
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52
Why are my nails splitting into multiple layers recently?
Is it because of a lack of nutrition? (Fig.52.1).
L, a woman in her 50s, used to put her hands in water a
lot but was surprised to discover that her ngernails had
recently split into several layers and came to see a doctor.
“I’ve never had this happen to my nails before, and I eat well,
so why is this happening?” she wondered (Fig.52.2).
Onychoschizia, also known as nail splitting or lamellar
dystrophy, refers to the condition where the nail plate splits
into one or multiple thin layers parallel to the surface of the
nail from the free edge. The nail plate is a fully keratinized
structure made up of about 25 dense layers of keratinocytes,
and onychoschizia occurs due to damage to intercellular
adhesive factors of the nail plate caused by various factors.
The most common factors that inhibit the adhesion between
the keratinocytes of the nail plate are frequent wetting and
drying of the nails, which is why it often occurs in housewives, cooks, beauticians, doctors, nurses, etc. Also, manicures, hardeners, polishes, removers, and other nail
cosmetics, nail procedures, and occupational exposure to
acids, alkalis, solvents, cement, etc. can be causes. Trauma
and habits such as nail biting and repetitive typing can also
be causes. It can also be observed in endocrine diseases,
tuberculosis, Sjogren’s syndrome, kidney diseases, nutritional deciencies (vitamins, iron, zinc), etc. and can appear
in cancer treatments, vitamin A derivatives (acitretin, etretinate) intake, psoriasis, lichen planus, fungal infections, etc.
It usually doesn’t hurt, but it can cause cosmetic or functional problems and is reported to be associated with depression. In most cases, it appears from the distal part, but in the
case of psoriasis or lichen planus patients taking retinoids, it
can occur from the proximal part. It can occur in conjunction
with onychorrhexis or onycholysis, which can be caused by
the same causes (Figs. 52.3–52.5, 52.6, 52.7, 52.8, 52.9,
52.10, 52.11, 52.12, 52.13 and 52.14).
We need to nd a way to strengthen the binding of the
keratinocytes of the nails for treatment. The number of times
the nails “get wet and dry (moisture and dryness)” should be
reduced. Avoid direct contact with water and wear rubber or
vinyl gloves over cotton gloves. Keep the nails neatly
Fig. 52.1 Onychoschizia
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_52
Fig. 52.2 Onychoschizia
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