Malnutrition of the nail. Bo lines. Methods for treating nail plate dystrophy

V.Yu. Vasenova, Yu.S. Butov

15.1. General information

Nails, like the epidermis, are formed from horny cells, some of which retain fragments of the cell nucleus.

Embryologically, they develop from the outer germ layer - the ectoderm in the 3rd month of intrauterine life and have the appearance of a small flat thickening and keratinization of the epidermis on the dorsal surface of the terminal phalanges of the fingers. Behind and on the sides of this thickening, nail folds are formed due to a slight protrusion of the skin in this area, from which the nail matrix subsequently develops. From the multiplying epithelial cells of the matrix, a nail plate is formed, which slowly grows in the distal direction and gradually becomes keratinized. Only at the 7-8th month does the nail completely occupy the nail bed and protrude beyond the soft tissues of the terminal phalanx of the finger.

Depending on the causative factors determining the development of destructive changes in the nail plates, manifested by dystrophy of varying degrees of severity, A.M. Arievich and L.T. Shetsiruli in 1976 proposed a clinical classification dividing all diseases of the nostrils into 6 groups.

I. Infectious diseases of the nail apparatus (fungi, bacteria). II.Onychia and paronychia in skin diseases (psoriasis, lichen planus, eczema, neurodermatitis, alopecia, pemphigus, etc.). III. Lesions of the nail apparatus due to internal, infectious, neuropsychic, endocrine and other systemic diseases.

IV. Traumatic and occupational onychia and paronychia. V. Neoplasms of the nail apparatus. VI. Congenital, hereditary onychia.

15.2. Onychodystrophy

The term “nail dystrophy” (onychodystrophia) refers to trophic changes in the nail plate, nail bed and ridges.

The clinical manifestations of onychodystrophy and the types of changes in the nail plates are diverse, as are the reasons that cause them. In other words, onychodystrophy is one of the symptoms of infectious, skin, internal, and neuropsychiatric diseases. Dystrophic lesions of the nails may be one of the manifestations of a systemic disease or syndrome |1). Very often, dystrophic changes in the nail apparatus develop under the influence of traumatic injuries to the nail plate, nail bed or nail folds of a mechanical, physical, chemical, biological nature and depend on the frequency, strength and duration of repeated parasite effects.

Thus, harmful effects of a local or general nature, intoxication, diseases of the nail matrix can cause degenerative changes in the nail plate itself. Thus, in a number of common diseases, for example, cirrhosis of the liver, psoriasis, lichen planus, changes in the nail plates, and sometimes in the nail folds of the hands and feet, have quite characteristic features

and can contribute to the timely diagnosis of the disease.

Below we will consider individual types of onychodystrophies.

Transverse groove of the nail (furrowBo). A transverse, or rather arcuate, groove that crosses the surface of the nail plate from one side fold to the other is one of the most common types of nail dystrophy. A transverse groove, sometimes with a slightly raised ridge along its posterior edge, appears on the surface of the nail plate after inflammation or trauma to the posterior nail fold or after damage to the nail skin during manicure (Fig. 15.1). The appearance of furrows is associated with eczema and psoriasis, especially if the rashes are localized on the dorsum of the hands. Bo's grooves can appear on the nails of the fingers and toes 1-2 weeks after suffering neuropsychiatric, infectious or systemic diseases in which the function and nutrition of the nail matrix are disrupted.

In 1936 M.V. Veksel described the appearance of Bo's furrow in children who had measles, scarlet fever and other childhood infections.

With minor trauma, Bo's groove is mostly superficial, but with severe damage to the nail matrix it can be deep, dividing the entire thickness of the nail into two halves. In such cases, the distal part of the nail plate gradually loses connection with the nail bed, becomes whitish and separates from the bed, while the proximal part of the nail continues its normal growth. Thus, by the depth of Bo's groove one can judge the severity of damage to the nail matrix.

If injury to the matrix is ​​repeated at short time intervals, then several transverse grooves appear, located sequentially, one after the other, as a result of which the surface of the nail plate becomes wavy.

Rice. 15.1. Furrows Bo.

Thus, Bo's groove is an onychodystrophy caused by a disruption of the normal function of the nail matrix of an exo- or endogenous nature.

Treatment for this onychodystrophy involves eliminating and preventing the occurrence of traumatic factors in the area of ​​the nail matrix, nail fold, nail skin, including during manicure (see Fig. 15.1).

Longitudinal grooves of the nail. The formation of longitudinal grooves occurs in cases of peripheral circulation disorders, traumatic injuries to the matrix or nail bed, nerve endings in the phalanges of the fingers, as well as lichen planus, psoriasis, gout, chronic rheumatoid polyarthritis and other chronic diseases.

The grooves on the nail plates can be single, located mainly in the central part of the plate, or multiple, occupying the entire surface of the nail. Cases of the formation of two grooves along the lateral edges of the nail in arterial hypertension, coronary insufficiency, and diseases of the spinal cord have been described; in this case, the central part of the nail plate becomes wider and somewhat flattened with two narrow zones on the sides.

Treatment for this onychodystrophy also involves the elimination and prevention of provoking factors.

Onychorrhexis(onychorrhexis) - splitting of the nail plate in the longitudinal direction. At the bottom of a nail groove, especially a deep one, even with minor and rarely recurring injuries, a crack can easily form. Initially, the groove splits on the free edge of the nail, then the crack increases in length towards the nail matrix. Depending on the nature of the disease underlying nail dystrophy, onychorrhexis most often occurs on the fingers of the hands, less often on individual toes.

Onychorrhexis is often combined with thimble-shaped dystrophy, onycholysis in eczema, psoriasis, and is especially pronounced in lichen planus. Longitudinal grooves and cracks in the nails often develop in patients with leprosy, varicose veins, and endocrine pathology.

The development of onychorrhexis can also be caused by constant contact with alkali solutions, formaldehyde, weak acids and other active chemicals that dry out the nail plate.

Like other onychodystrophies, onychorrhexis is often observed in patients with fungal nail infections.

Onychoschisis(onychoschizis) - dystrophy of nails in the form of their splitting. Unlike onychorrhexis, splitting of the nail plate in onychoschisis occurs not in the longitudinal, but in the transverse direction, parallel to the free edge of the nail. In this case, the nail grows normally until the free edge, after which it begins to split (2-3 layers or more), breaks off, or continues to grow in the form of two or three very thin plates lying one on top of the other. There are no inflammatory phenomena of soft tissues.

Nails II are most often affected. III and IV fingers. If nails

cut short, they acquire a normal appearance, but their regrown free edge becomes stratified again.

In the pathogenesis of onychoschisis, the main role belongs to frequently repeated trauma. This type of onychodystrophy occurs predominantly in women who often do manicures using various varnishes and acetone to remove them. A similar picture can develop among housewives who systematically do hand washing using alkaline soap and synthetic detergents.

Onychoschisis, like onychorrhexis, is observed in patients with eczema and lichen planus.

Treatment of onychorrhexis and onychoschisis involves the use of the same means as in the treatment of other nail dystrophies. Avoid injuries, maceration of the skin of the fingers and cut your nails short.

Brittle nails(fragilitas unguium) is one of the most common dystrophies of the nail plates, developing predominantly in women and often combined with other manifestations of onychodystrophy. As a rule, the free edge of the nail plate breaks off with the destruction of all layers, or the destruction is limited only to the top layer, leaving an uneven fringed edge. Increased fragility of the nail depends on the frequency and quality of manicure, after which the free edge of the nail, nail skin (eponychium), and nail folds are subject to frequent traumatic injuries, exposure to varnish, acetone, pure alcohol, hydrogen peroxide and other substances.

In women, brittle nails can gradually develop due to maceration of the skin of the hands under the influence of hot water and detergents, detergents, which cause thinning of the nail plates, the appearance of longitudinal grooves and cracks.

Fragility of the nail plates, along with other types of onychodystrophy, develops with hypothyroidism, as well as

with leprosy and syphilis. Treatment of the underlying disease can lead to elimination of brittle nails or reduction of onychodystrophy. And finally, congenital brittleness of nails is noted; Thin nail plates are especially brittle.

To treat brittle nails, vitamin A is prescribed orally at a dose of 200,000 IU per day for a long time, calcium and gelatin preparations. A daily finger massage at night is helpful.

Onycholysis(onycholysis) is a type of nail dystrophy often encountered in dermatologist practice, characterized by a disruption of the connection between the nail plate and the nail bed while maintaining the integrity of the latter. We are talking, therefore, not about the dissolution or melting of the nail, but only about its inability to grow to the nail bed.

Separation of the nail plate from the bed begins at the free distal edge and gradually progresses towards the proximal edge to the nail lunula area. In most cases, the part of the nail separated from the bed is no more than half the length of the entire nail plate; relatively rarely, the entire nail is separated. The part of the plate separated from the nail bed usually retains its normal consistency and smooth surface, but acquires a whitish-grayish color. The exception is cases of onycholysis of fungal and bacterial etiology, when the nail plate can become deformed, its surface becomes uneven, and color changes (Fig. 15.2).

Depending on the size of the separated part of the nail, onycholysis is distinguished between partial (o. partialis) and total (o. totalis). With partial onycholysis, the separated part of the plate in some cases looks like a strip along the free edge of the nail, in others, onycholysis is limited to the separation from the nail bed of only a small area on the free edge of the nail

Rice. 15.2. Onycholysis.

in the shape of a crescent, with its convex side facing the base of the nail, or in the shape of a trapezoid.

The following types of onycholysis are distinguished:

traumatic onycholysis;

onycholysis for psoriasis, eczema, neurodermatitis, etc.;

onycholysis for systemic diseases (syphilis, etc.);

onycholysis for endocrine disorders;

onycholysis for fungal and bacterial infections.

Treatment for this onychodystrophy is aimed at eliminating the factors that provoked its development.

Onychomadesis(onychomadesis) is a relatively rare type of onychodystrophy, which is characterized by separation of the entire nail plate from the bed, not from the free edge, as in onycholysis, but from the proximal part. In contrast to slowly progressing onycholysis, onychomadesis usually develops in a short time.

Onychomadesis of the nails of the hands and feet occurs on one, several, and occasionally on all fingers. Mostly the nails on the big toes are torn off.

The process of separation of the nail plate from the bed depends on the nature of the disease and can occur acutely, with inflammatory phenomena, accompanied by pain and visible

Rice. 15.3. Koilonychia.

inflammatory reaction, or without subjective sensations.

Onychomadesis can occur after severe trauma to the nail phalanx of the finger. Cases of relatively rapid rejection of the nail with rapidly occurring paronychia with onychia caused by fungi of the genus Candida or pathogenic bacteria have been described.

Reports of the development of onychomadesis in scarlet fever (during the period of active peeling of the skin of the hands), severe form of alopecia areata, and tabes dorsalis are described.

In some cases, the mechanism of onychomadesis remains unclear, although the cause is usually associated with poor circulation and pathology of the nail matrix. When matrix function is restored, a new, healthy nail plate grows. However, if patients with recurrent onychomadesis develop atrophy of the nail bed, the process ends with anonychia.

Treatment of patients suffering from onychomadesis can be effective only in cases where the etiology of this dystrophy can be established. All therapeutic measures should be aimed at restoring the normal function of the matrix and nail matrix, improving

blood supply, elimination of neurotrophic disorders. Vitamin therapy, finger massage, novocaine blockades, angioprotectors, oral gelatin are prescribed; it is necessary to treat the underlying disease.

Koilonychia(koilonychia) is characterized by the formation of a more or less deep saucer-shaped depression on the surface of the nail plate. The nail plate with true koilonychia usually remains smooth, of normal thickness, with the gradual formation of a saucer-shaped, spoon-shaped or cup-shaped depression in the central part, so that drops of water do not flow out in this area (Fig. 15.3).

Koilonychia usually develops on the nails of the hands, most often on the 2nd and 3rd fingers, and very rarely occurs on the toenails. More often than not, several nail plates are affected, but sometimes all nails are involved in the pathological process.

The exact mechanism of koilonychia is not clear, but there is an opinion that koilonychia can be congenital, familial, or hereditary. Cases of koilonychia in several generations have been described, which makes it possible to classify them as congenital anomalies.

In some cases, koilonychia is formed during onychomycosis.

Thimble-shaped welt of the legs -tey(onychia punctata), or the so-called thimble symptom, is one of the onychodystrophies that often occur in certain dermatoses and systemic diseases.

Clinically, this dystrophy is characterized by the appearance on the surface of the nail plate of small, pinpoint depressions and pits, corresponding in size to the depressions on the thimble. In 1928, G. Milian described these pits under the name “nail erosions.” In psoriasis they are round, in late syphilis they are oval or elongated. The number of pits on the surface of the nail varies

Sh

within wide limits; the nail plate becomes rough and resembles the surface of a thimble or wax pierced with a needle. The depth of the pits in eczema is mostly insignificant; in psoriasis and syphilis they are deeper. In some cases, the pits are randomly scattered on the surface of the nail, in others they are located in parallel rows in the form of transverse or longitudinal short lines (Fig. 15.4).

Thimble-shaped nail wear occurs in psoriasis, eczema, exfoliative dermatitis, alopecia areata, vitiligo and other diseases. Pinpoint impressions on the nails, clinically very similar, are often found in alopecia areata, exfoliative dermatitis, and eczema of the hands. With these dermatoses, the dimples are more superficial and less abundant. With the universal form of vitiligo and generalized alopecia, nail dystrophy develops, manifested by increased fragility, the appearance of horizontal cracks and pinpoint elements on the surface of the nail (Lerner syndrome).

We observed thimble-shaped wear of the nails, which preceded the development of lichen planus, eczema, psoriasis, which gives reason to consider this oni-

Rice. 15.4. Thimble-shaped wear of nails.

hodystrophy as a marker and harbinger of serious dermatosis.

Median canaliform dystro-nail art. This type of onychodystrophy has a polyetiological nature and a polymorphic clinical picture. More often, a deep channel-shaped groove 4-5 mm wide is observed in the central part of the nail plate, originating at the root of the nail, gradually moving towards the free edge and dividing it into two equal parts. Sometimes longitudinal bo-

Rice. 15.5. Median canaliform nail dystrophy.

the discharges are wider, but less deep, with lamellar peeling at the bottom, with cracks and splitting on the distal edge of the nail plate; The grooves are localized on the lateral parts of the nail plate. Most often the nail plates of the first fingers of the hands are affected, less often - all other fingers (Fig. 15.5). Cases of the development of this pathology in members of the same family have been described.

Gapalonychia(hapalonychia) is characterized by a pronounced softening of the nail plate, which easily bends and breaks off with the formation of cracks along the free edge. Impaired sulfur metabolism plays a role in the pathogenesis of this onychodystrophy.

Nail patterns appear on the free edge of the nail plate as a result of constant scratching of the skin with itchy dermatoses. Clinically, the free edge of the affected buttocks appears ground down, somewhat concave, the surface of the nail plates becomes glossy, glossy, and polished.

Anonychia(anonychia) - absence of the nail plate, which is a kind of developmental defect. Such a defect can occur on some or all fingers and toes in epidermolysis bullosa, as well as in true pemphigus, if the pathological process involves the nail phalanges of the hands and feet, including the matrix and nail bed.

Rejection of the nail plate can occur after severe trauma to the nail phalanx of the finger with the development of a subungual hematoma.

Thus, anonychia can be either congenital (anonychia congenita) or acquired (anonychia acquisita). Timely diagnosis of anonychia determines treatment tactics and prognosis.

Pterygium of the nail(pterigium unguis) - a type of onychodystrophy characterized by wing-shaped growth of the eponychium (nail skin) in length

and its movement towards the distal edge of the nail plate as it grows.

Pterygium can be a congenital abnormality or one of the symptoms of ectodermal dysplasia. Normally, the eponychium extends from the nail fold to the nail plate by less than 1 mm. In onychodystrophy, conventionally called “pterigium,” the nail skin appears significantly elongated and otherwise covers the entire nail plate.

In some cases, excess nail skin covering the proximal part of the nail plate can be observed in healthy people on the fourth and fifth toes.

On the hands, pterygium is found in people who have the habit of biting their nails (onychophagia), who suffer from Raynaud’s disease, sclerodactyly, and iterative endarteritis. In this case, the nail plates become thinner, the posterior nail fold atrophies, the length of the nail skin increases, and the boundaries between it and the nail fold, as well as between the eponychium and the nail plate, are erased.

In rare cases, pterygium is formed during dystrophic changes in patients with red planitis and psoriasis.

Treatment of pterygium consists of eliminating traumatic factors in the area of ​​the nail fold and nail skin, carefully separating it from the nail plate using a “dull” scalpel and subsequent removal with thin scissors.

Platonychia(platonychia) - dystrophy of the nail plate, in which its surface looks flat, without a normal convexity; described in 1910 Heller "(J. Heller).

It is believed that this type of hand nail dystrophy is quite rare and refers to abnormalities in the development of the nail plate. According to some data, platonychia is caused by professional factors. In both cases, they are usually affected

all or most of the nail plates. Sutton)