Nail disorders comprise approximately 10% of all dermatological conditions and affect a high percentage of the elderly.
Various changes and disorders are seen in the aging nail, many of which are extremely painful, affecting stability, ambulation and other functions. The prevention and management of these conditions require periodic cutting of the nails and appropriate medical care. Unfortunately, these are difficult for the elderly because of thickness of the nails, difficulty in accessing the feet, poor vision and sometimes, lack of motivation for personal care. This article reviews the age associated nail changes and disorders along with related management.Senile changes in nails
The senile changes in the nails are thought to result from impaired peripheral circulation, commonly due to arteriosclerosis.
Though nail plate is an efficient sunscreen,
UV radiation may play a role in such changes. Trauma, faulty biomechanics, infections, concurrent dermatological or systemic diseases and their treatments are also contributory factors.
The following changes are observed in human nails as part of the aging process:a) Alteration in chemical composition
The calcium and iron contents of the aging nails are increased and decreased respectively.b) Alteration in histology
The nail plate keratinocytes are increased in size, with increased number of 'pertinax bodies,' which are remnants of keratinocyte nuclei. The nail bed dermis shows thickening of the blood vessels and degeneration of the elastic tissue, especially beneath the pink part of the nail.c) Alteration in nail growth
Fingernails and toenails grow at an average rate of 0.1 mm/day (3.0 mm/month) and 0.03 mm/day (1.0 mm/month) respectively.
In the elderly, the rate of nail growth decreases by approximately 0.5%/year between 25 to 100 years of age.
As observed by Oreintreich and Scharp (1967),
thumbnail growth decreases on an average by 38% between the third and the ninth decade. In this study, the decrease in growth of nails in females was greater up to the sixth decade; thereafter no change was observed till the eighth decade, whereas in males, the slowing was more pronounced from the sixth to the eighth decade.d) Alteration in nail color
Senile nails may appear pale, dull, and opaque, with the color ranging from white (leuconychia) or yellow to brown or grey.
Leuconychia may be true (due to matrix involvement), which may be total, subtotal, transverse, punctate or longitudinal; pseudoleu-conychia (of exogenous origin), seen in onychomycosis, and keratin granulations after nail enamel application; and apparent leuconychia (due to changes in the underlying tissue).The clinical presentations are varied like
i) Terry's nails:
The nails are colored white proximally and have a distal normal pink band of 0.5-3 mm width. These are seen in seen in cirrhosis of the liver, chronic congestive heart failure, adult-onset diabetes mellitus and malnutrition.
ii) Half and half nails of Lindsay:
Seen in uremic patients, the nails have a proximal dull white area with the distal 20-60% portion brownish.
iii) Muehrcke's paired, narrow white bands:
The bands are present parallel to the lunula. This is seen in hypoalbuminemia (less than 2.2g/100ml),
nephrotic syndrome, glomerulonephritis, malnutrition, acrodermatitis enteropathica
or following chemotherapy.
iv) The lunula may be decreased or absent altogether.
v) Neapolitan nails, which can be seen in up to 20% of the persons older than 70 years, are characterized by three bands similar to the colors of Neapolitan ice-cream, i.e. a proximal white portion with absent lunula, a central normal pink band and an opaque distal free edge.e) Alteration in contour
Senile nails usually have an increased transverse curvature and a decreased longitudinal curvature. Flattening of the nail plate (platyonychia), spooning (koilonychia), and pincer nail deformity (involution), are found more frequently.
, f) Alteration in surface texture
Normally, the nails have a smooth surface. The senile nail may have increased longitudinal striations due to altered turnover rate of the matrix cells. The striations are termed "onychorrhexis" if they are superficial and "ridges" or "sausage-link ridges" or "beading" if deep.
Aging is the commonest cause of onychorrhexis.
Beau's lines (transverse ridges) and pitting are also found frequently.
The nails may be rough (trachyonychia) with splitting and fissuring.g) Alteration in thickness
Fingernails have a normal average thickness of 0.6 mm in males and 0.5 mm in females. Toenails are thicker, 1.65 ±0.43 mm and 1.38±0.2 mm in males and females respectively.
The nail plates of the thumb and great toe are the thickest, whereas the little finger has the thinnest nail plate. In the elderly, the nail plate thickness may increase, decrease or may remain unchanged.