Derm Dx: Severe ridging along the nails - Clinical Advisor

Derm Dx: Severe ridging along the nails

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A patient aged 45 years presents complaining of ridging along her nails. She denies trauma. She also denies rubbing or manipulating her proximal nail fold. The patient was diagnosed with depression, which she treats with venlafaxine.

Habit tic nail deformity is a defect in the nail plate caused by repetitive self-inflicted trauma to the nail matrix, most often seen on the thumb. It presents as a central nail plate depression that has several transverse ridges. This...

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Habit tic nail deformity is a defect in the nail plate caused by repetitive self-inflicted trauma to the nail matrix, most often seen on the thumb. It presents as a central nail plate depression that has several transverse ridges. This depression presents from the proximal nail fold and extends to the distal tip of the nail.

The trauma is usually inflicted by the tip of the patient’s second finger or fingernail. There is a correlation between intensity of the trauma and the size and severity of the defect. Patients usually report either an unconscious manipulation of the proximal nail fold or an itch under the proximal nail bed; although, frequently, patients deny manipulation.

This condition can present in children or adults. Habit tic nail deformity can be a presenting symptom of an anxiety or obsessive compulsive disorder. Onychotillomania is a severe form of habit tic nail deformity where the patient constantly picks at or tears off the nail.

Treatment involves cessation of the trauma, which can be achieved by advising the patient or caretaker to break the habit. Also, occluding the nail and nail matrix with tape or gloves is an effective therapy. Cognitive behavioral therapy strategies can help patients with anxiety management. A selective seratonin reuptake inhibitor (SSRI) may be considered for refractory cases.

Differentials

Onycholysis is the separation of the nail plate from the nail bed. It is most often caused by psoriasis or onychomycosis. Significant nail trauma can also be a cause. Other causes include hand dermatitis (eczema), herpes, hypo/hyperthyroidism, and porphyria. Treatment includes maintaining a dry nail bed and clipping away any excess nail.

Psoriasis is a papulosquamous inflammatory skin disorder. Nail findings in psoriasis include pitting, onycholysis, subungual hyperkeratosis, oil spots, and nail crumbling. 

Also known as leukonychia striata or transverse leukonychia, Mees’ lines is the appearance of multiple, white, parallel, transverse lines across the nail plate of several or all digits. It can be a normal variant, or it can appear from minor trauma, such as manicures. It has also been associated with drug use from chemotherapeutic agents or poisoning with arsenic or thallium. Mees’ lines can also be seen in systemic illnesses such as Kawasaki disease or HIV.

Jason Preissig, MD, is a graduate of Baylor College of Medicine.

Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine in Houston.

References

  1. William J, Berger T, Elston D. 2011. “Chapter 33 – Diseases of the Skin Appendages.” Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunder Elsevier. Print.
  2. Bolognia J, Jorizzo J, Rapini R. 2008. “Chapter 70 – Nail Disorders” Dermatology. St. Louis, MO: Mosby/Elsevier. Print
  3. Sweeney SA, Cohen PR, Schulze KE.Cutis. 2005. PubMed PMID: 15839359.
  4. Hoy NY, Leung AK, Metelitsa AI, Adams S. ISRN Dermatol. doi: 10.5402/2012/680163.
  5. Perrin AJ, Lam JM. Habit-tic deformity. CMAJ. 2014 Mar 18;186(5):371. doi: 10.1503/cmaj.121942.
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