242-245
Clinicalrheumatology, 1990, 9, N ~ 2
Case R e p o r t
Nail involvement in osteoarthritis M.
CUTOLO,
M.A.
CIMMINO,
S. A C C A R D O .
C a t t e d r a di Reumatologia, Istituto Scientifico di Medicina Interna, Universita' di Genova, Italy. SUMMARY Two cases of nail involvement associated with primary interphalangeal osteoarthritis of the hand, including leukonychia and longitudinal nail ridge, are reported. Osteoarthritic changes of the distal interphalangeal joints may cause nail lesions by exerting direct pressure on the nail matrix or by interfering with local blood flow. Moreover, inflammation of the Heberden's nodes is often present and seems to participate in the development of nail alteration. In our patients, leukonychia disappeared after local steroidal anti-inflammatory treatment of the osteoarthritic node and longitudinal nail ridge disappeared after treatment with nonsteroidal anti-inflammatory agents. Key words: Osteoarthritis, Nail, Heberden's Nodes. INTRODUCTION Several rheumatic diseases are associated with lesions of the nail matrix, the germinative part of the nail apparatus. In osteoarthritis (OA), nail changes have been reported in Kashin-Beck disease, a rare variant of generalized OA induced by ingestion of cereals contaminated by fungi (1). In addition, few cases of nail changes associated with Heberden's nodes have been reported in the literature (2,3), the most common lesion being ridging and concavity of the involved nail. In spite of these observations, recent rheumatology textbooks (4,5) and a treatise on diseases of the nails (6) still do not adequately consider this aspect. This report is concerned with two additional cases of nail involvement occurring in patients with primary OA of the distal interphalangeal joints (DIP).
Received: 4 December 1989 Revision-accepted: 26 January 1990 Correspondence to: Maurizio CUTOLO M.D., Via Domenico Cbiodo 25c/4, 16136 Genova, Italy.
CASE REPORTS
Case 1
A 62-year-old housewife without any relevant clinical history complained of progressive deformity of the DIP's of two years' duration. She had symmetrical Heberden's nodes without clinical signs of local inflammation. The DIP of her right thumb was deformed by a dorsal osteophyte. The nail showed a longitudinal red groove with elevated margins that enlarged in triangularshaped areas at both distal and proximal extremities (Fig. la). There was no history of local trauma, or tics or habits that might have resulted in nail damage. Routine blood laboratory examinations were within the normal range. Radiograms showed two marginal osteophytes on the dorsal aspects of the corresponding DIP (Fig. lb). The patient was given a 2-week course of naproxen 500 rag/daily and parenteral glycosaminoglycan polysulphate 30 mg twice
Nail involvement in osteoarthritis
243
Fig. 1: a) Longitudinal ridging with elevated margins and beaded extremities of the nail of the thumb with
Heberden's node. b) The X-ray shows two large osteophytes on the dorsal side of the corresponding distal interphalangeal joint. weekly for 2 months. Thereafter, a normal nail appeared proximally and, with its growth, the ridge disappeared. Therapy was stopped but 3 months later a similar lesion recurred. Case 2
A 73-year-old man had a one-year history of pain and reduced articular function of the DIP's of both hands. Painful, swollen, redish Heberden's nodes were present at clinical evaluation. The DIP of the second left finger was especially enlarged and showed thickening and discoloration of the nail plate (leukonychia) (Fig. 2a). The lunula was absent, and the nail surface was smooth. Laboratory investigations were within normal limits. Radiograms showed narrowing of the articular space and subchondral sclerosis, as well as subperiosteal bone apposition and osteo-
phytes of the distal phalanx (Fig. 2b). Ultrasonographic study of the nail vascular bed was consistent with slight reduction of the blood flow in comparison to that of the controlateral finger. The patient was treated with three weekly intraarticular injections of triamcinolone hexacethonyde (5 mg) and 2% lidocaine chlorhidrate solution (800 ~tL). After 15 days, swelling and pain diminished with improvement of articular function. After 30 days, the nail plate was normal, and showed a distinct lunula (Fig. 2a, inset). DISCUSSION The nail changes of both patients were probably related to damage of the nail matrix elicited by osteoarthritic involvement of the DIP's. Several common causes of nail matrix damage, such as systemic metabolic diseases,
244
M. Cutolo, A. Cimmino, S. Accardo
Fig. 2: a) Discoloration of the nail and disappearance of the lunula in the left index finger of a patient with inflamed Heberden's node. The controlateral index finger is shown for comparison. Inset: the nail of the left index finger after treatment, b) X-ray shows narrowing of the joint space, subchondral sclerosis, and osteophytes of the involved joint. The DIP of right index is fused.
mycosis, trauma, and infarcts of the vascular servation of a recurrence of the nail lesion after treatment had been stopped. bed were ruled out. Leukonychia, observed in the second paWe believe that in the first patient the large dorsal osteophyte, probably associated with a tient as a probable consequence of the inmucinous cyst (7) underlying the matrix, flamed node, has not been previously decould have interfered mechanically with nail scribed in association with OA of the DIP growth. The nail lesion should correspond to joints. In this patient, nail damage could be median canaliform dystrophy, which often af- ascribed to another mechanism. Inflamed fects the thumbs (8) It is usually caused by Heberden's node may affect trophism of the pressure on the nail matrix exerted by tumors nail matrix by exerting pressure on it or, alor by self-inflicted trauma. Likewise, subun- ternatively, by impairing local blood flow. In fact, Heberden's nodes on the dorsolatgual exostosis, (9) an outgrowth of normal bone tissue or calcified cartilagineous debris, eral and/or dorsomedial aspect of the DIPs can destroy the nail plate or elevate the nail. with degenerative 'wear and tear' lesions ocThe nail usually recovers its normal appear- cur in most cases of interphalangeal OA. Sevance when these causes are removed, provid- eral features of Heberden's nodes, such as ed they are not long-standing. In the present vascular congestion, swelling, pain, or erosion case, the decreased size of the myxoid cyst of cartilage and bone, point to an inflammaunderlying the nail matrix could be a conse- tory cause. quence of the course of anti-inflammatory Effective local treatment supported the therapy. This effect is supported by the ob- view that hyperthrophic and inflamed tissue
Nail involvement in osteoarthritis
of the n o d e could have induced nail damage. The relationship between i m p r o v e m e n t of local inflammation, following pharmacological or surgical t r e a t m e n t and r e a p p e a r a n c e of normal nail features has b e e n r e p o r t e d (2,3). The possibility exists, however, that recovering could be also be due to an additional biochemical influence on nail matrix. However, local injections of corticosteroid crystal suspension have b e e n r e p o r t e d to be ineffective in uncomplicated leukonychia (10). In conclusion, H e b e r d e n ' s n o d e s may be associated with typical nail changes, which
245
are rare in c o m p a r i s o n to the prevalence of O A of the DIPs. T h e pathogenesis of these changes could be related to different possible mechanisms. A c k n o w l e d g m e n t : W e thank Prof. F r a n c o Crovato, Divisione di Dermatologia, O s p e d ale di Chiavari, for helpful discussions, Dr. Carlo M. Pesce, National C a n c e r Institute, N I H , Bethesda, and Ms. Selena Kerins for reviewing the manuscript.
REFERENCES 1. Nesterov, A.I. The clinical course of Kashin-Beck disease. Arthritis Rheum 1964, 7, 29-40. 2. Alarcon-Segovia, D., Vega-Ortiz, J.M. Heberden's nodes' nails. J Rheumatol 1981, 8, 509-511. 3. Goldman, J.A., Goldman, L., Jaffe, M.S., et al. Digital mucinous pseudocysts. Arthritis Rheum 1977, 20, 997-1002. 4. Kelley, W.N., Harris, E.D. jr., Ruddy, S., Sledge, C.B. Textbook of Rheumatology, WB Saunders, Philadelphia, 1989. 5. McCarthy, D.J. Arthritis and Allied Conditions, Lea & Febiger, Philadelphia, 1988.
6. Baran, R., Dawber, R.P.R. Diseases of the Nails and Their Management, Blackwell, Oxford, 1984. 7. Goldman, G.A. Heberden's nodes' nails and pseudocysts. J. Rheumatol 1982, 9, 162. 8. Rehtijarvi, K. Dystrophia unguis mediana canaliformis (Heller). Acta Derm Venereol 1971, 51, 315319. 9. Norton, L.A. Nail disorders. J Am Acad Dermatol 1980, 2, 451-467. 10. Zaias, N. The nail in health and disease. MTP Press Ltd., Lancaster, 1980.
Clinicalrheumatology, 1990, 9, N ~ 2
Case R e p o r t
Nail involvement in osteoarthritis M.
CUTOLO,
M.A.
CIMMINO,
S. A C C A R D O .
C a t t e d r a di Reumatologia, Istituto Scientifico di Medicina Interna, Universita' di Genova, Italy. SUMMARY Two cases of nail involvement associated with primary interphalangeal osteoarthritis of the hand, including leukonychia and longitudinal nail ridge, are reported. Osteoarthritic changes of the distal interphalangeal joints may cause nail lesions by exerting direct pressure on the nail matrix or by interfering with local blood flow. Moreover, inflammation of the Heberden's nodes is often present and seems to participate in the development of nail alteration. In our patients, leukonychia disappeared after local steroidal anti-inflammatory treatment of the osteoarthritic node and longitudinal nail ridge disappeared after treatment with nonsteroidal anti-inflammatory agents. Key words: Osteoarthritis, Nail, Heberden's Nodes. INTRODUCTION Several rheumatic diseases are associated with lesions of the nail matrix, the germinative part of the nail apparatus. In osteoarthritis (OA), nail changes have been reported in Kashin-Beck disease, a rare variant of generalized OA induced by ingestion of cereals contaminated by fungi (1). In addition, few cases of nail changes associated with Heberden's nodes have been reported in the literature (2,3), the most common lesion being ridging and concavity of the involved nail. In spite of these observations, recent rheumatology textbooks (4,5) and a treatise on diseases of the nails (6) still do not adequately consider this aspect. This report is concerned with two additional cases of nail involvement occurring in patients with primary OA of the distal interphalangeal joints (DIP).
Received: 4 December 1989 Revision-accepted: 26 January 1990 Correspondence to: Maurizio CUTOLO M.D., Via Domenico Cbiodo 25c/4, 16136 Genova, Italy.
CASE REPORTS
Case 1
A 62-year-old housewife without any relevant clinical history complained of progressive deformity of the DIP's of two years' duration. She had symmetrical Heberden's nodes without clinical signs of local inflammation. The DIP of her right thumb was deformed by a dorsal osteophyte. The nail showed a longitudinal red groove with elevated margins that enlarged in triangularshaped areas at both distal and proximal extremities (Fig. la). There was no history of local trauma, or tics or habits that might have resulted in nail damage. Routine blood laboratory examinations were within the normal range. Radiograms showed two marginal osteophytes on the dorsal aspects of the corresponding DIP (Fig. lb). The patient was given a 2-week course of naproxen 500 rag/daily and parenteral glycosaminoglycan polysulphate 30 mg twice
Nail involvement in osteoarthritis
243
Fig. 1: a) Longitudinal ridging with elevated margins and beaded extremities of the nail of the thumb with
Heberden's node. b) The X-ray shows two large osteophytes on the dorsal side of the corresponding distal interphalangeal joint. weekly for 2 months. Thereafter, a normal nail appeared proximally and, with its growth, the ridge disappeared. Therapy was stopped but 3 months later a similar lesion recurred. Case 2
A 73-year-old man had a one-year history of pain and reduced articular function of the DIP's of both hands. Painful, swollen, redish Heberden's nodes were present at clinical evaluation. The DIP of the second left finger was especially enlarged and showed thickening and discoloration of the nail plate (leukonychia) (Fig. 2a). The lunula was absent, and the nail surface was smooth. Laboratory investigations were within normal limits. Radiograms showed narrowing of the articular space and subchondral sclerosis, as well as subperiosteal bone apposition and osteo-
phytes of the distal phalanx (Fig. 2b). Ultrasonographic study of the nail vascular bed was consistent with slight reduction of the blood flow in comparison to that of the controlateral finger. The patient was treated with three weekly intraarticular injections of triamcinolone hexacethonyde (5 mg) and 2% lidocaine chlorhidrate solution (800 ~tL). After 15 days, swelling and pain diminished with improvement of articular function. After 30 days, the nail plate was normal, and showed a distinct lunula (Fig. 2a, inset). DISCUSSION The nail changes of both patients were probably related to damage of the nail matrix elicited by osteoarthritic involvement of the DIP's. Several common causes of nail matrix damage, such as systemic metabolic diseases,
244
M. Cutolo, A. Cimmino, S. Accardo
Fig. 2: a) Discoloration of the nail and disappearance of the lunula in the left index finger of a patient with inflamed Heberden's node. The controlateral index finger is shown for comparison. Inset: the nail of the left index finger after treatment, b) X-ray shows narrowing of the joint space, subchondral sclerosis, and osteophytes of the involved joint. The DIP of right index is fused.
mycosis, trauma, and infarcts of the vascular servation of a recurrence of the nail lesion after treatment had been stopped. bed were ruled out. Leukonychia, observed in the second paWe believe that in the first patient the large dorsal osteophyte, probably associated with a tient as a probable consequence of the inmucinous cyst (7) underlying the matrix, flamed node, has not been previously decould have interfered mechanically with nail scribed in association with OA of the DIP growth. The nail lesion should correspond to joints. In this patient, nail damage could be median canaliform dystrophy, which often af- ascribed to another mechanism. Inflamed fects the thumbs (8) It is usually caused by Heberden's node may affect trophism of the pressure on the nail matrix exerted by tumors nail matrix by exerting pressure on it or, alor by self-inflicted trauma. Likewise, subun- ternatively, by impairing local blood flow. In fact, Heberden's nodes on the dorsolatgual exostosis, (9) an outgrowth of normal bone tissue or calcified cartilagineous debris, eral and/or dorsomedial aspect of the DIPs can destroy the nail plate or elevate the nail. with degenerative 'wear and tear' lesions ocThe nail usually recovers its normal appear- cur in most cases of interphalangeal OA. Sevance when these causes are removed, provid- eral features of Heberden's nodes, such as ed they are not long-standing. In the present vascular congestion, swelling, pain, or erosion case, the decreased size of the myxoid cyst of cartilage and bone, point to an inflammaunderlying the nail matrix could be a conse- tory cause. quence of the course of anti-inflammatory Effective local treatment supported the therapy. This effect is supported by the ob- view that hyperthrophic and inflamed tissue
Nail involvement in osteoarthritis
of the n o d e could have induced nail damage. The relationship between i m p r o v e m e n t of local inflammation, following pharmacological or surgical t r e a t m e n t and r e a p p e a r a n c e of normal nail features has b e e n r e p o r t e d (2,3). The possibility exists, however, that recovering could be also be due to an additional biochemical influence on nail matrix. However, local injections of corticosteroid crystal suspension have b e e n r e p o r t e d to be ineffective in uncomplicated leukonychia (10). In conclusion, H e b e r d e n ' s n o d e s may be associated with typical nail changes, which
245
are rare in c o m p a r i s o n to the prevalence of O A of the DIPs. T h e pathogenesis of these changes could be related to different possible mechanisms. A c k n o w l e d g m e n t : W e thank Prof. F r a n c o Crovato, Divisione di Dermatologia, O s p e d ale di Chiavari, for helpful discussions, Dr. Carlo M. Pesce, National C a n c e r Institute, N I H , Bethesda, and Ms. Selena Kerins for reviewing the manuscript.
REFERENCES 1. Nesterov, A.I. The clinical course of Kashin-Beck disease. Arthritis Rheum 1964, 7, 29-40. 2. Alarcon-Segovia, D., Vega-Ortiz, J.M. Heberden's nodes' nails. J Rheumatol 1981, 8, 509-511. 3. Goldman, J.A., Goldman, L., Jaffe, M.S., et al. Digital mucinous pseudocysts. Arthritis Rheum 1977, 20, 997-1002. 4. Kelley, W.N., Harris, E.D. jr., Ruddy, S., Sledge, C.B. Textbook of Rheumatology, WB Saunders, Philadelphia, 1989. 5. McCarthy, D.J. Arthritis and Allied Conditions, Lea & Febiger, Philadelphia, 1988.
6. Baran, R., Dawber, R.P.R. Diseases of the Nails and Their Management, Blackwell, Oxford, 1984. 7. Goldman, G.A. Heberden's nodes' nails and pseudocysts. J. Rheumatol 1982, 9, 162. 8. Rehtijarvi, K. Dystrophia unguis mediana canaliformis (Heller). Acta Derm Venereol 1971, 51, 315319. 9. Norton, L.A. Nail disorders. J Am Acad Dermatol 1980, 2, 451-467. 10. Zaias, N. The nail in health and disease. MTP Press Ltd., Lancaster, 1980.
