| AGEING NAILS | ArTicle
embarrassing as the irregular free margin of the nail tends to catch on clothing and fine stockings. Pertinax bodies, which are onion-shaped keratin bodies of the nail’s undersurface and bulge into the matrix, may induce narrow red streaks, again often leading to a notch in the distal edge of the nail. Nails that grow at a slower rate have a tendency to
become brittle, especially in women, and lose their shine and transparency (Figures 3 and 4). While slow nail growth in the fingernails usually leads to thinner, fragile and dull nails, the toenails often become thicker, more yellowish and opaque (Figure 5). This may also be because slow- growing nails accumulate more noxious physical and chemical influences, such as lipid solvents, detergents, dirt, and ultraviolet light. Microscopically, the onychocytes become larger with age. Slow nail growth also loosens the nail plate–nail bed attachment, which is normally very tight (Figure 6). This explains why onycholysis is more common in the elderly, more difficult to treat, and tends to recur more easily. However, careful clinical examination is necessary to rule out isolated nail psoriasis. Dermatoscopy may help to discern the frequently occurring tiny splinter haemorrhages in the nail bed. Psoriasis of the nail bed also exhibits a brownish margin of the onycholysis (Figure 7), which is not the case in onycholysis semilunaris as a result of overzealous manicure.
Frequent nail alterations of the elderly Apart from these nail alterations, which may be seen as physiologic, there are a variety of changes seen more frequently in older individuals. Platonychia (flat nail) and koilonychia (spoon
nail) may be signs of an iron deficiency, leading to a desynchronisation of the proliferation rate of the proximal and distal matrix. In the normal nail, the former matrix portion has a higher proliferation rate, therefore the dorsal nail overgrows the ventral layers, giving it its characteristic and slight longitudinal convex curvature. This proliferation pattern is apparently reversed in iron deficiency so that the distal matrix grows faster with the consequence of heaping up of the distal nail plate. Nail dystrophy may be a sign of very
old age, but is sometimes seen in those in their seventh decade without any obvious reason. Some treatments for other conditions, such as the anticoagulant warfarin, which is often prescribed following myocardial infarction,
lung
embolism, a stroke or venous thrombosis, may cause a nail dystrophy similar to that observed in amyloidosis or long-standing ungual lichen planus. This has also been
Figure 4 Dull ridged nail with onychoschizia (macrophotograph)
Figure 5 Thick yellowish, intransparent, overcurved big toenails of a 62-year-old man
While slow nail growth in the fingernails usually leads to thinner,
fragile and dull nails, the toenails often become thicker, more yellowish and opaque.
observed — though much more rarely — during treatment with the anticoagulant heparin. Venous insufficiency, in contrast, is often associated with very thick, yellow crumbly nails. This may even be exaggerated in chronic lymphatic stasis with pachydermia and onychogryposis. The latter is also commonly seen in debilitated or immobile individuals, and is almost always associated with foot deformities, such as flat and spread foot, as well as
hallux valgus and hammer toes. While actinic keratosis and solar elastosis are
commonplace in light-skinned people, actinic damage of the nail bed is very rare as the thick keratin plate is an excellent ultraviolet shield. Nail psoriasis is not a rare event in the elderly (Figure 7).
It is even more recalcitrant to treatment in older people than younger individuals and any systemic treatment should carefully consider the potential risks and benefits, as well as potential drug interactions. Fungal nail infections proportionally increase in prevalence up to the age of 80 years and then remain stable. Slow nail growth, insufficient blood supply, decreased physical activity, diminishing immune functions and often potentially immunodepressive drugs, increase the susceptibility
to onychomycosis (Figure 8 — overleaf) (7). Chronic paronychia is more frequent in older female patients. The aetiology may be allergic, fungal or bacterial, and sometimes combined. Green nails (chloronychia syndrome) are usually owing to the bacterium Pseudomonas aeruginosa, and may be associated with a dermatophyte or mould infection. These patients may be a risk for very young grandchildren whose immune systems have not yet fully matured, and they should also not
care for those who are severely-ill. Proteus and Klebsiella spp may colonise the nail surface, often under the proximal nail fold or adjacent to the lateral folds. They
prime-journal.com | May 2011 ❚ 61
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