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LETTER TO THE EDITOR
Year : 2016  |  Volume : 13  |  Issue : 1  |  Page : 47-48

Dirty nails in hyperthyroidism


1 Department of Endocrinology, PIMS, Thiruvalla, Kerala, India
2 Department of Medicine, PIMS, Thiruvalla, Kerala, India

Date of Web Publication5-Jan-2016

Correspondence Address:
Rajeev Philip
Department of Endocrinology, PIMS, Thiruvalla, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-0354.168877

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How to cite this article:
Philip R, Sivaraman SC, John SM, Sankaran KC. Dirty nails in hyperthyroidism. Thyroid Res Pract 2016;13:47-8

How to cite this URL:
Philip R, Sivaraman SC, John SM, Sankaran KC. Dirty nails in hyperthyroidism. Thyroid Res Pract [serial online] 2016 [cited 2019 Nov 22];13:47-8. Available from: http://www.thetrp.net/text.asp?2016/13/1/47/168877

Sir,

Onycholysis in hyperthyroidism has become a rarity in the current era due to early detection and management of hyperthyroidism. The classical Plummer's nails are uncommonly encountered in clinical practice, but when present, give a clue to the diagnosis of thyrotoxicosis. We report such a case.

A 35-year-old female presented with a history of weight loss, palpitations and increased frequency of stools of 1-year duration. On examination, she had resting tachycardia with a pulse rate of 112/min, fine tremors of the extremities, and a diffuse goiter with thyroid bruit. Investigations confirmed the diagnosis of thyrotoxicosis, with T3 289 ng/dl (80–200), T4 22.9 μg/dl (4.5–12.5) and thyroid-stimulating hormone 0.001 μIU/ml (0.35–5.50). A technetium uptake scan showed a diffusely enlarged gland with increased uptake suggestive of Graves' disease.

She also complained that her nails were always dirty and on examination her nails were shiny with longitudinal striations with flat surface and terminal onycholysis, with trapped dirt [Figure 1] and [Figure 2] suggestive of Plummer's nails. Skin manifestations are common in hyperthyroidism and onycholysis was described in around 5% patients as per older literature.[1] However, recent literature describes Plummer's nails as a rare finding, and the incidence is limited to case reports.[2] This finding was first reported by Dr. Henry S. Plummer of the Mayo Clinic and he described onycholysis, longitudinal striations and flattening of the nail producing a scoop shove appearance in long-standing hyperthyroidism, which was, later, named after him.[3] In hyperthyroidism, there is an increase in the rate of growth of the nail, as compared to the nail bed, which results in separation of the nail from the nail bed - terminal onycholysis. Catabolism of nail and nail bed proteins is also thought to contribute to the development of this finding.[4],[5] The fourth finger is most commonly affected.[5] Dirt gets trapped in between the nail and nail bed, giving it a black appearance and hence called dirty nails of hyperthyroidism.
Figure 1: Terminal onycholysis with longitudinal striations and trapped dirt

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Figure 2: Flat and concave nails

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Plummer's nails indicate long standing thyrotoxicosis, irrespective of the cause [4] and help in differentiating Graves' disease from viral thyroiditis.

 
  References Top

1.
Caravati CM Jr, Richardson DR, Wood BT, Cawley EP. Cutaneous manifestations of hyperthyroidism. South Med J 1969;62:1127-30.  Back to cited text no. 1
    
2.
Atia A, Johnson BS, Aldelmalak HD, Sinnot B. Onycholysis (Plummer's nail) in a patient with hyperthyroidism. Endocr Pract 2008;14:132.  Back to cited text no. 2
    
3.
Luria MN, Asper SP Jr. Onycholysis in hyperthyroidism. Ann Intern Med 1958;49:102-8.  Back to cited text no. 3
    
4.
Singh G. Nails in systemic disease. Indian J Dermatol Venereol Leprol 2011;77:646-51.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Leonhardt JM, Heymann WR. Thyroid disease and the skin. Dermatol Clin 2002;20:473-81, vii.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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