A 50-year-old female patient presented to me with discoloration of her toenails. Her family asked her to have her nails checked out as she could be “contagious” and have nail fungus. She had no other pertinent medical history or medications of relevance. She had no pain associated with her nails and related no history of trauma.
The nails had been discolored for some time. A previous physician diagnosed her with onychomycosis and prescribed topical ciclopirox lacquer (Penlac). She had been using that product for over a year. She noticed no improvement since using the topical and presented to me for another opinion.
During the clinical exam, I noticed that all of her toenails had a milky white discoloration that ended about 1 mm from the distal edge of the nail. The lunulae were obscured. All except the left great toenail were even in thickness. Otherwise, all nails had a normal curvature and length. In addition to the white discoloration, the left great toenail had clinical signs of onychomycosis: thickness, some subungual debris and yellow streaking.
I also examined her fingernails for comparison. All fingernails were uniformly white with the discoloration ending about 1 mm from the nail edge. The unaffected area of the nail on both toes and fingers was a healthy pink color. The signs of onychomycosis were only present in one out of 20 nails.
The nails displayed leukonychia but why and what type? In my mind, this presentation immediately elicited Terry’s nails or the apparent leukonychia associated with liver cirrhosis. Of course, I was sitting in front of a seemingly healthy patient who hadn’t had labs drawn in a while and doesn’t have a review of systems and social history that lead me down the path of liver dysfunction, congestive heart failure or renal insufficiency. I sent the patient for a workup that included hepatic function as well as other values and encouraged her to follow up with her family physician for a routine exam. The results of her blood work returned within normal limits.
A next step I could perform is a biopsy of the nail bed. Past reports show a change in vascularity in the dermis of the nail bed in patients with Terry’s nails.1
While investigating Terry’s nails further, I found reports linking the condition to malnutrition, actinic keratosis and aging.1 Scher and Daniel reported it can be present in the absence of any systemic disease.2 Others have felt it is a manifestation of abnormal steroid metabolism, abnormal ratio of estrogen to androgens and/or increased blood flow to the digit.3
So my working diagnosis is Terry’s nails with an idiopathic cause. Certainly, this is a patient I will continue to monitor and encourage to see her family physician on a regular basis.
The message from this case is not all dystrophic nails are mycotic. Granted, I am still refining my diagnosis and searching for a more definitive answer, but I encourage you to really consider what dermatologic condition(s) is/are presenting. Nail disease is so much more extensive than dermatophyte invasion. It is often a fascinating insight into the systemic and rheumatologic conditions that may be affecting the patient.
1. Holzberg M, Walker HK. Terry’s nails: revised definition and new correlations. Lancet. 1984; 1(8382):896-9.
2. Lawry M, Daniel CR. Nails in systemic disease. In: Scher RK, Daniel CR (eds): Nails: Diagnosis, Therapy, Surgery, third edition, chapter 15. Elsevier Saunders, Philadelphia, 2005, pp. 154-55.
3. Rubin AI, Baran R. Physical signs. In: Baran R, de Berker D, Holzberg M, Thomas L (eds). Baran and Dawber's Diseases of the Nails and their Management, fourth edition, chapter 2, Wiley-Blackwell, Hoboken, NJ, 2012, pp. 89-90.