This patient has Terry’s nails.
Terry's nails is a type of apparent leukonychia with ground glass opacification of the majority of the nail, obliteration of the lunula, and a normal or pink nail bed at the distal nail border. This condition can be observed in liver cirrhosis, chronic renal failure, and congestive heart failure. Terry’s nails can also be associated with normal aging. The clinical appearance is due to a change in nail bed vascularity and overgrowth of connective tissue.
(Witkowska et al. Indian J Dermatol 2017)
There are three types of apparent leukonychia (white discoloration of the nail that fades with pressure):
-
Terry’s nails are due to a nail bed defect that occurs in up to 80% of patients with liver cirrhosis. The leukonychia is evenly white and involves the entire nail excluding only the distal 1 to 2 mm of the nail. These changes can also be observed in patients with congenital heart failure, diabetes, chronic renal failure, and in healthy individuals.
-
Muehrcke’s nails are a result of an abnormal vascular bed and are commonly seen in patients receiving combination chemotherapy. The nail exhibits double white multiple transverse bands that run parallel to the lunula. Muehrcke’s nails can also be observed in patients with nephrotic syndrome, low albumin levels, liver disease, and malnutrition.
-
Half-and-half nails (Lindsay’s nails) are due to nailbed edema and are observed in ~25% of patients with chronic kidney disease who are undergoing dialysis. The leukonychia involves the proximal ½ of the nail with the distal ½ being normal. Half-and-half nails can also be observed in normal individuals.
True leukonychia (white opaque punctate, striate, or diffuse discoloration of the nail that does not fade with pressure) is secondary to matrix damage. The loss of transparency is due to parakeratotic cells in the ventral plate. It is usually insignificant and related to trauma, but can be associated with chemotherapeutic agents.
Mee’s lines can be seen in arsenic poisoning. They are transverse white lines that affect all nails and grow out with the nail plate.
This patient does have
onycholysis but does not have oil spots or pitting characteristic of psoriasis. The primary finding is Terry’s nails and the onycholysis is a secondary finding.
Beau’s lines are the classic nail finding in chemotherapy. They are transverse depressions that are more evident in the central portion of the nail plate and are secondary to proximal nail matrix dysfunction. Other nail abnormalities that can be observed with chemotherapy include Muehrcke’s nails (apparent leukonychia with white discolored bands that fade with pressure and do not move with the nail plate), longitudinal melanonychia, onycholysis, onychomadesis (periodic proximal nail detachment), onychorrhexis (longitudinal striations, ridging, fissuring, thinning of nail plate), paronychia, and true leukonychia.
Clinical Pearl: Terry’s nails are an apparent leukonychia which is evenly white and involves the entire nail excluding only the distal 1 to 2 mm of the nail. This condition can be observed in liver cirrhosis, chronic renal failure, congestive heart failure, and in aging patients without associated systemic disease.
