Onycholysis

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Onycholysis is a nail disorder frequently encountered by dermatologists. Onycholysis is characterized by a spontaneous separation of the nail plate starting at the distal free margin and progressing proximally. In onycholysis, the nail plate is separated from the underlying and/or lateral supporting structures. Less often, separation of the nail plate begins at the proximal nail and extends to the free edge, which is seen most often in psoriasis of the nails (termed onychomadesis). Rare cases of onycholysis are confined to the nail’s lateral borders.

See the images below.

Nails with onycholysis usually are smooth, firm, and without inflammatory reaction. Onycholysis is not a disease of the nail matrix, but nail discoloration may appear underneath the nail as a result of secondary infection. When onycholysis occurs, a coexistent yeast infection is suggested. Treating primary and secondary factors that exacerbate onycholysis is important. Left untreated, severe cases of onycholysis may result in nail bed scarring.

Endogenous, exogenous, hereditary, and idiopathic factors can cause onycholysis. Contact irritants, trauma, and moisture are the most common causes of onycholysis, but other associations exist.

Systemic diseases and states in onycholysis are as follows:

Amyloid and multiple myeloma

Anemia (iron deficient)

Bronchiectasis

Diabetes mellitus

Erythropoietic porphyria

Histiocytosis X

Hyperthyroidism

Hypothyroidism

Ischemia (peripheral, impaired circulation)

Leprosy

Lupus erythematosus

Neuritis

Pellagra

Pemphigus vulgaris

Pleural effusion

Porphyria cutanea tarda

Pregnancy

Psoriatic arthritis

Reiter syndrome

Sarcoidosis

Scleroderma

Shell nail syndrome

Syphilis

Yellow nail syndrome

Dermatologic diseases in onycholysis are as follows:

Psoriasis

Lichen planus

Dermatitis

Hyperhidrosis

Pachonychia congenita

Congenital ectodermal defect

Pemphigus vegetans

Lichen striatus

Atopic dermatitis

Congenital abnormalities of the nail

Neoplastic disorders in onycholysis are as follows:

Squamous cell carcinoma (of nail bed)

Carcinoma (lung)

Nonmicrobial factors in onycholysis (may be encountered at the job site, ie, as occupational onycholysis) are as follows:

Mechanical – Mechanical force (trauma), repetitive minor trauma, or maceration

Chemical – Allergic or irritant contact dermatitis from various nail cosmetics (methyl methacrylate monomer, formaldehyde 1-2%, nail base coat/hardeners, polymerized 2-ethylcyanoacrylate adhesive used in artificial nails, nail lacquer), gasoline, paint removers, dicyanodiamide, thioglycolate, solvents, and hydroxylamine sulphate in color developer

Chemical – Irritant contact dermatitis from prolonged immersion of nails in water, sugar onycholysis in confectioners/bakers, and exposure to highly destructive toxins (eg, hydrofluoric acid)

Biologic/microbial factors are as follows:

Dermatophytosis (ie, Trichophyton rubrum, Trichophyton mentagrophytes infection)

Yeast (Candida infection)

Bacteria (Pseudomonas infection)

Virus (herpes simplex infection)

Photo-induced associations, with medication and subsequent exposure to sunlight, are as follows:

Tetracycline and its derivatives

Psoralens

Fluoroquinolones

Chloramphenicol

Benoxaprofen

Chlorpromazine

Chlortetracycline

Demethylchlortetracycline

Doxycycline ^{[1, 2]}

Minocycline

Oral contraceptives

5-Methoxypsoralen (Psoraderm 5)

Aminolevulinic acid (from phototherapy) ^[3]

Olanzapine ^[4]

Aripiprazole ^[4]

Griseofulvin ^[5]

Photo-induced associations with onycholysis, without medication and exposure to sunlight, are as follows:

Spontaneous photo-onycholysis ^[6]

Bullous photo-onycholysis (during pseudoporphyria resulting from hemodialysis)

Non-photo–induced associations with onycholysis ^[7] are as follows:

Doxorubicin

Mitoxantrone

Captopril

Bleomycin

5-Fluorouracil (capecitabine) ^{[8, 9]}

Retinoids

Tetracycline

Etoposide

Paclitaxel ^[10]

Docetaxel ^{[10, 11]}

Hydroxylamine

These include the following:

Congenital onycholysis

Hereditary partial onycholysis

Idiopathic acquired onycholysis

Hereditary distal onycholysis ^[12]

Foreign body implantation

The worldwide incidence of onycholysis is unknown.

Distribution of onycholysis by race is unknown; however, onycholysis has been observed in persons of all races.

Individuals of either sex can have onycholysis; however, studies demonstrate an overwhelmingly female predilection.

People of any age can present with onycholysis, although it primarily is a disease of adulthood.

Severe cases of onycholysis that are left untreated may result in nail bed scarring.

Educate patients with onycholysis about avoiding possible contact irritants, trauma, and moisture.

For patient education resources, see the Skin, Hair, and Nails Center, Psoriasis Center, and Yeast and Fungal Infections Center, as well as Nail Psoriasis and Onychomycosis.

Passier A, Smits-van Herwaarden A, van Puijenbroek E. Photo-onycholysis associated with the use of doxycycline. BMJ. 2004 Jul 31. 329(7460):265. [Medline]. [Full Text].

Rabar D, Combemale P, Peyron F. Doxycycline-induced photo-onycholysis. J Travel Med. 2004 Nov-Dec. 11(6):386-7. [Medline].

Hanneken S, Wessendorf U, Neumann NJ. Photodynamic onycholysis: first report of photo-onycholysis after photodynamic therapy. Clin Exp Dermatol. 2008 Aug. 33(5):659-60. [Medline].

Gregoriou S, Karagiorga T, Stratigos A, Volonakis K, Kontochristopoulos G, Rigopoulos D. Photo-onycholysis caused by olanzapine and aripiprazole. J Clin Psychopharmacol. 2008 Apr. 28(2):219-20. [Medline].

Bentabet Dorbani I, Badri T, Benmously R, Fenniche S, Mokhtar I. Griseofulvin-induced photo-onycholysis. Presse Med. 2012 Jan 12. [Medline].

Horio T. Spontaneous photo-onycholysis. J Dermatol. 1988 Dec. 15(6):540-2. [Medline].

Makris A, Mortimer P, Powles TJ. Chemotherapy-induced onycholysis. Eur J Cancer. 1996 Feb. 32A(2):374-5. [Medline].

Hogeling M, Howard J, Kanigsberg N, Finkelstein H. Onycholysis associated with capecitabine in patients with breast cancer. J Cutan Med Surg. 2008 Mar-Apr. 12(2):93-5. [Medline].

Paravar T, Hymes SR. Longitudinal melanonychia induced by capecitabine. Dermatol Online J. 2009 Oct 15. 15(10):11. [Medline].

Robert C, Sibaud V, Mateus C, Verschoore M, Charles C, Lanoy E, et al. Nail toxicities induced by systemic anticancer treatments. Lancet Oncol. 2015 Apr. 16(4):e181-e189. [Medline].

Tinio P, Bershad S, Levitt JO. Medical Pearl: Docetaxel-induced onycholysis. J Am Acad Dermatol. 2005 Feb. 52(2):350-1. [Medline].

Bazex J, Baran R, Monbrun F, Grigorieff-Larrue N, Marguery MC. Hereditary distal onycholysis–a case report. Clin Exp Dermatol. 1990 Mar. 15(2):146-8. [Medline].

Oram Y, Karincaoglu Y, Koyuncu E, Kaharaman F. Pulsed Dye Laser in the Treatment of Nail Psoriasis. Dermatol Surg. 2010 Jan 19. [Medline].

Edwards F, de Berker D. Nail psoriasis: clinical presentation and best practice recommendations. Drugs. 2009. 69(17):2351-61. [Medline].

Scotte F, Banu E, Medioni J, et al. Matched case-control phase 2 study to evaluate the use of a frozen sock to prevent docetaxel-induced onycholysis and cutaneous toxicity of the foot. Cancer. 2008 Apr 1. 112(7):1625-31. [Medline].

Scotte F, Tourani JM, Banu E, et al. Multicenter study of a frozen glove to prevent docetaxel-induced onycholysis and cutaneous toxicity of the hand. J Clin Oncol. 2005 Jul 1. 23(19):4424-9. [Medline].

Melanie S Hecker, MD, MBA President, Hecker Dermatology Group; Consulting Staff, Department of Dermatology, Imperial Point Medical Center, Holy Cross Hospital, and North Broward Hospital

Melanie S Hecker, MD, MBA is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, Medical Society of the State of New York

Disclosure: Nothing to disclose.

David Hecker, MD Consulting Staff, Dermatology Specialists of Palm Beach County

Disclosure: Nothing to disclose.

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD.

Richard K Scher, MD Adjunct Professor of Dermatology, University of North Carolina at Chapel Hill School of Medicine; Professor Emeritus of Dermatology, Columbia University College of Physicians and Surgeons

Richard K Scher, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American Medical Association, Association of Military Surgeons of the US, International Society for Dermatologic Surgery, Noah Worcester Dermatological Society, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Onycholysis

Research & References of Onycholysis|A&C Accounting And Tax Services
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