Nails in older adults

Figures & data

Table 1. Summary of common nail changes in older adults.

Diagnosis	Disease characteristics
Onychogryphosis	Thickening, hypertrophy, and brown opaque nail plate discoloration, most frequently affecting the great toenails [4,5,11]. Presents as ‘ram’s horn-like’ or ‘oyster-like’ with transverse striations, often associated with trauma, nail surgery, foot-to-shoe incompatibility, or hallux valgus [3,5,11].
Onychocryptosis	Ingrown toenail presenting with pain at rest, ambulation, or with pressure [5,8]. May be caused by trauma, weight fluctuation, hyperhidrosis, poor nail cutting, onychotillomania, history of nail surgery, obesity, bony abnormalities, onychomycosis, foot-to-shoe incompatibility, or hallux valgus [5,8].
Onychauxis/Pachyonychia	Localized nail plate hypertrophy with hyperkeratosis, discoloration, and decreased translucency with or without subungual hyperkeratosis and debris [3,5,6].
Onychophosis	Hyperkeratosis of the lateral or proximal nail folds, between the nail fold and nail plate, or subungual area [3,5]. The great and fifth toenails are most commonly affected, likely because they are most often subject to trauma [3,5].
Onychoclavus	Subungual heloma or corn presenting as hyperkeratosis with or without melanonychia overlying the nail bed typically affecting the distal great toenail [3,5]. May be due to trauma, foot-to-shoe incompatibility, digits flexi, hallux valgus, hammer toe deformity, or rotated fifth toes [5,6].
Subungual Hematoma and Splinter Hemorrhages	Violaceous, black nail plate discoloration that migrates distally with nail growth most likely due to trauma [5,17]. May be accompanied by onycholysis [5,17]. Splinter hemorrhages may be a sign of nail psoriasis [5].
1. Beau’s lines 2. Onychomadesis 3. Retronychia	1. Transverse grooves in the nail plate caused by a temporary decrease of mitotic activity of nail matrix keratinocytes [20,21]. 2. The complete nail plate separation and shedding with slow longitudinal growth rate after a traumatic event [20]. 3. The malalignment of the nail plate resulting in growth of the nail plate proximally towards the nail fold [24].
Onychomycosis	Fungal infection of the nail unit causing yellow nail plate discoloration, thickening, onycholysis, crumbling, and subungual hyperkeratosis [30].
Periungual and Subungual Warts	Caused by HPV [44]. Immunosuppression is a major risk factor [5].
Acute Paronychia	Bacterial infection of the nail folds, most commonly caused by Staphylococcus aureus [3,5]. Presents with erythema, tenderness, and localized pus formation [3,5]. Most likely due to trauma and typically affects one nail [3,5].
Chronic Paronychia	Nail fold inflammation with erythematous and swollen nail folds with cuticle loss [3,5].
Brittle Nail Syndrome (BNS)	Increased nail plate fragility, most frequently seen in women [48,48]. Presents with onychoschizia, onychorrhexis, or splitting [4,6].
Nail Psoriasis	Nail matrix psoriasis presents with pitting, crumbling, leukonychia, and red spots in the lunula [52]. Nail bed psoriasis presents with splinter hemorrhages, onycholysis, oil drops and nail bed hyperkeratosis [52].
Nail Unit Melanoma	Longitudinal melanonychia, or longitudinally oriented brown to black band that extends the length of the nail plate [61]. May present as amelanotic [63–65]. Concerning findings are bands measuring > 3 mm in width, band widening, heterogeneity in color, bleeding, and nail splitting [62]. Hutchinson’s sign is periungual pigment involving the nail folds or hyponychium is often concerning for invasive melanoma [63].
Bowen’s Disease	An ulcerated, hyperkeratotic lesion often accompanied by erythema, scaling, and crusting [69]. Risk factors include HPV, trauma, ionizing radiation, smoking, arsenic exposure, and chronic paronychia [6,71].
Myxoid Cyst	Skin-colored to translucent, smooth, dome-shaped, and fluctuant nodules located distal to the interphalangeal joint [34,72]. Most commonly on the first three fingers [34,72].

Figure 1. Pincer nail of the left first toenail in an 80-year-old woman. The lateral aspect of the nail plate is penetrating the periungual dermis of the lateral nail fold [8].

Figure 2. A 75-year-old female presented with painful bilateral great toenails for 10 years. Her nails grew slowly and were extremely difficult to clip. A full nail examination was significant for opaque yellow-brown thickening, hyperkeratosis, elongation, and increased curvature of the great toenails. Onychogryphosis can be differentiated from retronychia and onychomycosis by its spiral striated appearance [13].

Figure 3. Example of a patient-initiated nail hematoma selfie of the right thumbnail on the day of examination.

Patient-initiated nail hematoma selfie of the right thumbnail 1 month following the initial examination.

Patient-initiated nail hematoma selfie of the right thumbnail 2 months following the initial examination 18.

Figure 4. Clinical presentations of Beau’s lines, onychomadesis and retronychia. (A) Beau’s lines on the left toenails. (B) Onychomadesis of the left great toenail. (C) Retronychia of the right great toenail [20].

Figure 5. 93-year-old female with bullous pemphigoid presented with Beau’s lines on all fingernails at even intervals coinciding with her monthly IVIG treatments [23].

Figure 6. Physical examination findings in onychomycosis. A, Right great toenail with subungual hyperkeratosis and nail plate onycholysis. B, Left great toenail with yellow discoloration and onycholysis. C, Multiple toenails with subungual hyperkeratosis and onycholysis. D, Toenails with severe onychodystrophy and ridging. E, Scale on the plantar feet and web spaces [33].

Figure 7. Dermoscopy of onychomycosis. A, Fringed proximal margin of the onycholysis. B, Blurred yellow-orange-brown nail discoloration in longitudinal striae (the fading mimics Aurora Borealis). C, Distribution of the discoloration in longitudinal striae or round areas. D, Ruin-like appearance of the subungual scales that are white-yellow-orange in color. Photographs courtesy of Dr Maria Bianca Piraccini [34].

Figure 8. Chronic paronychia presenting with edema of the right third and fourth nail folds. Of note, there is also benign longitudinal melanonychia of the right 4th fingernail.

Figure 9. Clinical manifestations of brittle nail syndrome, including lamellar onychoschizia.

Figure 10. Nail pitting and onycholysis in right fingernails [20].

Figure 11. Dermoscopic appearance of subungual melanomas. B, Brown lines on a brown background, irregular color, thickness, and spacing with no loss of parallelism. C, Brown lines on a brown background, irregular color, thickness, and spacing with loss of parallelism[62].

Figure 12. A, A translucent compressible nodule of the proximal nail fold and longitudinal groove in the nail plate of the right thumb. B, Transillumination using a dermatoscope to project light from the dorsal digit through the nail unit demonstrated a central nodule in the proximal nail fold as well as a second cyst radially. (Reprinted with permission from Cutis. 2020;105(2):82. ©2020, Frontline Medical Communications Inc.) [73].

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Data availability statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study