Case Study 5

1. Case Study 5 68 year old man Self referral Reports unable to cut his toe nails because of thickness and shape

2. Further information • Medication: • Aspirin 75mgs • Cod Liver Oil • Glucosamine • DP and PT palpable, no sensory impairment

3. Onychauxis Abnormal thickening of the nails without deformity Onychogryphosis • Thickening and distortion of nail resembling claws or a ram’s horn

4. Causes of onychauxis & onychogryphosis • Diabetes • Impaired circulation • Nutritional deficiency • Psoriasis • Trauma • Infection • Acromegaly • Heredity

5. Pathology ofonychauxis Trauma to the nail matrix results in excess production of onychocytes (nail cells) and the nail becomes progressively thicker as it grows along the nail bed. (Johnson 2002) Pathology of onychogryphosis Spiral like appearance is believed to be due to uneven production of cells from the nail matrix – that is, the damaged side of the matrix produces cells at a slower rate. (Johnson 2002)

6. Differential Diagnosis • Rheumatoid arthritis • Peripheral vascular disease • Diabetic neuropathy • Onychomychosis • Psoriasis • Chronic pressure / trauma

7. Rheumatoid Arthritis • Rheumatoid arthritis: cod liver oil and glucosamine supplements indicate an arthritic condition • Thickened toenails can be a symptom of rheumatoid arthritis • Other symptoms to look out for: • pain, swelling and inflammation of the joints • joint stiffness • deformity of the joints of the feet and hands • fever and fatigue

8. Reactive arthritis / Reiter’s syndrome • Reactive arthritis is a short-lived condition that is thought to be caused by a previous infection disrupting the normal workings of the immune system. • Thickened toenails are a relatively rare symptom. More information from the patient concerning whether arthritic symptoms are present may indicate whether this is a likely cause: • Possible symptoms: • pain, swelling and stiffness in the joints • skin rashes • involved toes and finger swelling = ‘sausage digits’ • inflammation of the eyes causing pain, redness • cystitis – inflammation of the bladder or urinary tract

9. Peripheral vascular disease • 75 mgs of aspirin daily is the dose used to treat or prevent heart attacks, strokes, angina and peripheral vascular disease • Peripheral vascular disease(PVD) is peripheral arterial narrowing and hardening due to atheroma. The arteries that take blood to the legs are the most commonly affected. • One symptom of the advanced stage of PVD is thickened toe nails. • This seems an unlikely cause of his thickened toenails as both dorsalispedis and posterior tibialis pulses are palpable. However, further information could be gained from the patient concerning whether he suffers from intermittent claudication, burning in the legs and feet, a history of heart disease

10. Diabetes • Diabetic neuropathy: A diabetics sweating mechanism is altered and as a result dry, thickened toenails and cuticles can appear • Thickened toenails can be a symptom of diabetic neuropathy • Patient needs to be questioned further for other diabetic symptoms – polyuria, polydipsia, polyphagia, ulcers on the legs. It must be noted that there is no sensory impairment in the legs, helping to rule out diabetes

11. Onychomycosis • Fungal nail infection- it causes toenails to thicken, discolour, disfigure and split • Onychomycosis is the most common nail disease in adults that cannot be immediately ruled out without further tests • Tests: Samples would need to be taken and sent to the laboratory for analysis • Treatment: An oral medication such as terbinafine or an anti-fungal nailpaint could be prescribed There are various subtypes of onychomycosis: Distal lateral subungalonychomycosis (DLSO) – nail is thick, has a cloudy appearance, the nail bed thickens and hardens Total dystrophic onychomycosis (advanced form)– nail is thickened, opaque and yellow-brown. The nail plate and matrix are affected.

12. Psoriasis • Psoriasis: a common chronic skin condition resulting in patches of raised, red skin with silvery scales caused by a rapid turnover of skin cells over the body and the toenails • This causes a thickening, pitting and irregular contour of the nail also called psoriatic nail disease • Up to 25% of people with psoriasis have psoriatic arthritis of which 50-85% have nail disease • More information from the patient needs to be gathered concerning whether this condition is present in other areas of the body before this can be ruled out: • Look for: • skin changes on the elbows, knees, scalp and trunk • pitting of the nails • Beaus lines (lines going across the nails) • areas of white on nail plate • loosening and crumbling of the nail • thickening under the nail

13. Chronic pressure / trauma • Long-term pressure from shoes that are either too small or too narrow over the toes can cause thickening of the toenails • Dropping a heavy object on the toenails can cause permanent thickening • The greater the age, the greater the amount of repetitive trauma and pressure the toenails have to withstand resulting in thickened toenails • This is a likely cause. The patient’s shoes need to be examined for pressure marks both inside and outside of the shoe. It may be that a shoe with a deeper toe box needs to be worn in future

14. Lichen Planus • Lichen planus is an inflammatory condition that frequently affects the lower leg. • It can cause onychauxis with pitting on the nail – (although later the nail thins). • As the main presenting symptom is itch and a rash, a dermatological examination of the patient would determine if this is a likely cause. (Merriman)

15. PachyonychiaCongenita • PachyonychiaCongenita is a rare inherited disorder causing congenital thickening of the nail plate. • All of the nails are affected and nail bed (as opposed to nail plate) hypertrophy is the major feature. (Neale)

16. Darier’s disease • Darier’s disease is a systemic condition which can cause onychauxis, usually in several or all of the nails.

17. Short term treatment plan • Thin down the nails using nail burr and file • Examine footwear for signs of long term pressure and advise • Offer advice for keeping nails short and prevent nails re-thickening • Recommend shoes with a wider toe box • Take clippings from nail to send for analysis to rule in/out onychomycosis • Use information from patient to rule in/out likelihood of reactive or rheumatoid arthritis and psoriasis. Possibly refer to his GP to check for peripheral vascular disease

18. Long term treatment plan • Patient’s potential arthritis might mean that it is increasingly difficult to bend to cut his toe nails. For this reason, he may have to return every four to six weeks to have assistance in keeping his nails short and thinned down • If results from clippings indicate onychomycosis, then patient will have to return to receive treatment and advice. Will prescribe topical or oral anti-fungal medicines • If the nails are so misshapen that thinning is not providing relief, then total nail avulsion may have to be considered