NAIL CHANGES AND NAIL DISORDERS IN THE ELDERLY (2024)

Sir,

Long life is much desired but not all people are destined to enjoy it. The elderly population in India aged 60 years and above[1] is steadily growing and its absolute size is already quite large. As per SRS estimation in 2003, this population comprised 7.2% of the total population.[2]

Nail changes associated with ageing are common in the elderly and include characteristic modifications of color, contour, growth, surface, thickness, and histology. No cutaneous examination is complete without a careful evaluation of the nails. The calcium content of the ageing nail increases whereas the iron content of the ageing nail decreases.[3] Histologically, the keratinocytes of the nail plate are increased in size with increased number of ‘pertinax bodies’ (remnants of keratinocyte nuclei).[4] The nail bed dermis also shows thickening of the blood vessels and elastic tissue, especially beneath the pink part of the nail.[5] Nail growth decreases by approximately 0.5% per year between 20 and 100 years of age.[6]

This study has been undertaken for nail changes and nail disorders in the elderly because of the scarcity of such studies in our country.

Lots were drawn to randomly select every second elderly OPD patient aged 60 years and above for this study, irrespective of their presenting symptoms. A total of 100 patients were studied by this method to eliminate observers’ bias in the study.

A detailed history of each elderly patient was taken along with a detailed nail examination, an examination of the hair, and a general survey as per the proforma. We examined KOH preparations of nail clippings microscopically for all the suspected cases of onychomycosis to detect fungal elements.

The following table shows the age- and sexwise breakup of patients enrolled for the study. The details of age and sex distribution has been shown in Table 1.

The youngest patient in this study was 60 years old while the oldest patient was 101 years old; 6% had the habit of occasional nail biting.

The majority of the patients were not aware about their nail changes or nail diseases. However, nail disease was the presenting complaint in 14/100 cases.

A general survey showed that 44 patients had mild conjunctival pallor which raised the clinical suspicion of mild anemia. It was also seen that they suffered from various system diseases like hypertension (19%), diabetes mellitus (5%), COPD and bronchial asthma (5%), ischemic heart disease (4%), arthritis (2%), prostatic hypertrophy (1%), and Parkinsonism (1%).

Out of 100 patients, 98 showed at least one change due to ageing although two patients, both incidentally female, didn’t show any age-related changes.

Regarding age-related color change of the nail plate, 73% of the patients showed pale, dull, and lusterless nail plates, followed by opacity in 8% and grey color in 6%.

Lunular visibility decreases with increasing age and out of the 31 cases in whom the lunula was visible, 23 were 60–70 years old. In these 23 patients, lunular visibility was maximal (100%) in LF (first left finger = left thumb) and RF1 (first left great toe) followed by 67.8 and 64.5% for RT1 and RT2 respectively. Lunular visibility was very low or absent in other fingers and toes.

Among changes in the nail surface due to ageing, prominent longitudinal ridges were the most common change (85%) followed by rough nails in 33% of the patients, transverse ridges in 23%, and lamellar split in 15% of the cases.

Brittleness of the nail is a common condition related to ageing. Twenty-six males (40%) and eight females (26%) showed brittle nails. Toe nails were more likely to be brittle in both sexes. Among males, 25 had brittle toenails, five had brittle fingernails, and four had brittle finger- and toenails. Among females, eight had brittle toenails, two had brittle fingernails, and two patients had brittle finger- and toenails.

Onychauxis which is an age-associated thickening of the nail plate, was noticed in 23% of the patients and its prevalence was 10% in the left great toe and 13% in the right great toe, followed by 7% in the right 5^th toe and 4% in the left 4^th toe.

Among changes in nail contour, increased transverse curvature was seen in five cases, pincer nail in two, and platyonychia in one case.

Table 2 shows the prevalence of nail disorders in the elderly. Out of 33 cases of acquired disorders, the majority of them were infective disease. Onychomycosis was seen in 16%, followed by chronic paronychia in 9%; 31% showed a single disorder, 4% showed two disorders, and 1% showed three disorders.

The prevalence of onychomycosis was 22% in women and 12% in men. The most common change in onychomycosis is loss of luster, subungual hyperkerotosis, onycholysis, brittleness, and color change with blackish, brownish, or yellowish discoloration.

Of 16 cases of onychomycosis, fungal element could be found in ten cases (62.5%) in the KOH preparations. Diagnosis was made in the remaining cases when there was a high index of clinical suspicion, presence of dermatophytic lesions in some other body part, and absence of any cutaneous disorder that could explain similar nail changes.

Fingernails were involved in ten patients and toenails were involved in 12 patients.

Out of the nine patients who were suffering from chronic paronychia, five were male. Of these five males, three were retired, one a farmer, and another jobless. Of the four female patients, three were housewives and one a maid-servant. The right thumb, index, and ring fingers were affected in four cases each, the left thumb and the right middle finger in three cases while the left index, middle, ring and little fingers, right little finger and left toe were involved in two cases each. Thus, the right hand was found to be more commonly affected. Common changes seen in chronic paronychia were loss of cuticle, nail fold erythema, and edema. Common nail plate changes were transverse furrows, loss of luster, and thickening.

Traumatic nail disorders were the third most common disorder seen in the study in eight patients. Among these, subungual hematoma was seen in three cases, followed by nail loss in two and onycholysis in two cases. One case of splinter hemorrhage was also seen.

In our study, we found that senile changes in the elderly were studied under four headings:

1. Change in color with emphasis on lunular color change

2. Change in contour of nail

3. Change in the surface of the nail including brittle nail and

4. Gross change in thickness of the nail with presence of onychauxis.

The most common ageing change in the nail was a pale, dull, and lusterless appearance of the nail in 73% of the patients. The color of the ageing nail may vary from yellow to grey with a dull opaque appearance.[7] The senile nail may appear pale, dull, and opaque, with its color varying from white or yellow to brown to grey.[5]

Although the lunula is often not visible in all fingers and toes, as in our study, it is most consistently observed on the thumb, the index finger, and the great toe.[8]

Lunular size decreased with age and has been noted as an ageing-related nail change in elderly persons.[4] In our study, we found that the lunula was not visible in 69 cases and its visibility decreased consistently with age.

Ageing-related nail changes can be seen in the form of increased longitudinal furrowing or ridges and increased friability and fissuring.[9] Ageing is the most common cause of onychorrhexis or superficial longitudinal ridges.[10] Transverse furrows/ridges are also found very frequently. The nails may be rough (trachyonychia with lamellar splitting and fissuring). In our study, we found prominent/increased longitudinal ridges in 85% of the cases with no significant difference in the percentage of finger- and toenails. Transverse ridges/furrows (22%) were seen in the toenails of all 22 patients (mainly in the great toe nails) and in the fingernails of two cases. Rough nails (33%) were also seen, mostly in the toes.

Repeated cycles of hydration and dehydration occurring in excessive domestic wet work or overuse of dehydrating agents, nail enamel and nail enamel removers, and cuticle removers may cause brittleness of the nails. Brittle nails are a common finding in the elderly.[3,11] Consistent with the findings of Lubach et al. (31% in males and 36% in females ≥ 60 years and above),[11] we found the prevalence of brittle nails to be 34% in our patient sample. The first three fingers of the dominant hand are particularly susceptible to brittle nails. The incidence of brittle nails was, however, higher in the toenails in our study population because these patients were from poorer socioeconomic strata who walk barefoot or use ill-fitting shoes and sandals. Constant low-grade trauma hastens the brittle nail change that is seen in elderly patients.

Senile nails may have an increased transverse curvature and a decreased longitudinal curvature.[7] Flattening of the nail plate (platyonchia), spooning (koilonychia), and pincer nail deformity are found more frequently in the elderly.[5] In our study, we observed increased transverse curvature in five cases. We also found two cases of pincer nail and one case of platyonychia; no case of koilonychia was seen in our study.

The prevalence of onychomycosis increases with age and reaches nearly 20% in patients over 60 years of age.[12] In our study, we found the prevalence of onychomycosis to be 15%. Onychomycosis has been reported to be more common in elderly men than in elderly women.[13] In our study, we found that the prevalence of onychomycosis was 22% in women and 12% in men. The most common type of onychomycosis observed in our study was distal and lateral subungual onychomycosis, as also observed earlier.[14] Chronic paronychia (9%) was also not uncommon in the present study. The right hand, being the working hand of the majority, was found to be predominantly affected. Most of the patients in our study were from the poorer sections of the society. Many of them walk barefoot most of the time and due to their unsanitary dwelling habits, their feet are usually exposed to dirty and wet conditions. The above factors have been seen as inducing and hastening factors in causing brittle nails. Occupation as well as household work of many patients, especially the women, involve repeated minor trauma, and hand and foot exposure to water, chemicals, and irritants for long durations. These factors may be contributory to ageing-related changes in our study group as well as to onychomycosis and paronychia.

In our study, we found six cases of psoriasis, out of which four presented with nail changes. Prevalence of nail involvement in psoriasis was found to be 67%. Nail involvement is common in psoriasis and has been reported between 50[15] and 56%.[16] It is estimated that between 80 and 90% of psoriatics will suffer from nail disease during their lifetime.[17] Pitting was seen in all the four cases as the most common finding, as has been described by others.[18] Pitting was more common on the fingernails than on the toenails and was scattered rather than a regular pattern. Other common findings were subungual keratin deposits and onycholysis. Yellowish discoloration and loss of texture were also common findings. Although loss of cuticle has been a common finding,[3] it was not found in the present study.

With improved socioeconomic condition and awareness, more and more geriatric patients will visit dermatologists with nail-related problems in the future. Hence, dermatologists will have to brace themselves up beforehand to handle such common geriatric problems of this organ.

References