| AGEING NAILS | ArTicle Faulty biomechanics of the feet with hallux valgus is
common in the elderly. They may cause a subungual heloma, or onychoclavus, which is very painful. Outward rotation of the little toe may cause a corn on the lateral aspect opposite the nail root; however, a subclinical double nail of the little toe may induce the same painful characteristics and be the reason for its first diagnosis. Friction of the toes in the shoes with consequent haematoma is common. These friction haematomas are often localised over the nail bed of the medial aspect of the big toenail and may be mistaken for a melanoma, as this lesion is often non-migratory in contrast to subungual haematomas as a result of an acute trauma. However, melanin pigmentation in the nail is seen as a regular longitudinal streak emerging from under the proximal nail fold and running all along the nail plate to its free end. It can be seen with end-on dermatoscopy of the nail plate.
Malignant tumours of the nails As with most areas on the body, tumours become more frequent in the older population. Melanoma is the most common malignant nail neoplasm, and certainly the most serious. Despite the fact that between two thirds and three quarters of ungual melanomas are pigmented, most are diagnosed very late as evidenced by a number of large series of more than 100 nail melanomas each with a medium thickness between 3.2 mm and 4.7 mm, and more
Figure 9 Myxoid pseudocyst of the right middle finger. A. Clinical aspect with normal light. B. Transillumination
(diaphanoscopy) reveals the cystic nature of the lesion
than two thirds already in clinical stages 3 and 4 (11–14). This is a strong sign of indolence from the side of the patient, but also of physician negligence. Late diagnosis is the reason for the purportedly very poor prognosis of ungual melanomas, a feature also seen in other acral melanomas. Squamous cell carcinoma of the nail runs a relatively benign course with rare metastases. It usually presents as an onycholytic area with characteristic oozing, although it is also seen in benign subungual tumours with an eroded surface, such as pyogenic granuloma. In contrast to hairy skin, basal cell carcinoma of the nail is extremely rare and usually presents as an oozing exophytic tumour on the proximal nail fold.
Treatment Older ladies in particular, will often require treatment for their nail problems. It must be stressed that physiologic age changes are resistant to any therapy. A quick fix does not
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