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Letter to Editor
7 (
2
); 28-30
doi:
10.7324/jhsr.2022.726

Yellow Nail Syndrome and Associated Internal Disturbances

Department of Medicine, Armed Forces Hospital, Brasília-DF, Brazil
American Society of Neurophysiology, and Dermatologist of Brasília-DF, Brazil
University Center of Brasília-DF, Brasília-DF, Brazil
Department of Medicine, Catholic University of Brasília, Brasília-DF, Brazil
Email: vitorinomodesto@gmail.com
Licence
This open access article is licensed under Creative Commons Attribution 4.0 International (CC BY 4.0). http://creativecommons.org/licenses/by/4.0

How to cite this article: dos Santos VM, Sugai TAM, Modesto LC, Modesto JC. Letter Yellow Nail Syndrome and Associated Internal Disturbances. J Health Sci Res 2022;7(2):28-30.

Abstract

Nail changes detected during the general physical examination can contribute to establish initial diagnostic hypothesis and may enhance the awareness about some associated internal disorders. In approximately half of the cases, the changes are detected without being a present complaint. Main causes are dermatological diseases, infections, trauma, drug-related, and genetic entities. Yellow nail syndrome includes lung disorder, pleural effusion, and lymph edema of lower limbs; renal failure, hypothyroidism, malignant tumor, Saint’s triad, and pericarditis are related with. The aim of the comments is emphasizing the role of nails evaluation to yield diagnostic clues.

Keywords

Clinical diagnosis
Nail
Yellow nail syndrome

Dear Editor,

Nail changes are easily observed during the inspection step of the general physical examination and may offer diagnostic clues on internal disturbances1-10. Recently, we read the interesting paper by Goyal et al. highlighting the observation of abnormalities on this often neglected skin appendage. They emphasized clinical patterns, etiologies, and risk factors for various nail changes, and the role of accurate inspection of the nails during physical examination, in addition to the causal relationships between ungual abnormalities and some internal diseases. Their study included 200 outpatient individuals evaluated on an Indian tertiary care hospital, with the mean age of 37.98 ± 16.79 years, and male (1:1.29) predominance. The major number (60%) of the studied patients had between 21 and 50 years of age. Nail changes were detected in 54.5% of cases without this presenting complaint, while the patient was undergoing an examination for some dermatological or systemic disturbances. The fingernails were affected in 42% of the patients, and 20 nails in only 10.5%. Dermatological disease was the major cause of nail changes (45%), followed by nail infections (36%), and systemic, traumatic, genetic, and drug-related etiologies (19%). Nail discolorations (91 cases) were as follows: Yellow (31.87%), black (28.57%), white (25.27%), green (8.79%), red (3.30%), and blue (2.20%), with more prevalence in onychomycosis. The authors highlighted that the nails deserve greater attention for systemic diagnoses1. In this setting, may be appropriate to add commentaries on the yellow nail syndrome (YNS), a scarcely reported entity first described by Samman and White in 19641-10. Noteworthy, the syndrome has been considered very uncommon, but seems in fact underdiagnosed.

YNS may be characterized by the yellowish discoloration and dystrophic nails (thickening, hardening, increased convexity, transversal ridging, onycholisis, onychorrexis, paronychia, deficient cuticles, absence of lunules, and slow growth), associated with respiratory disturbances (asthma, bronchitis, sinusitis, bronchiectasis, pneumonitis, and pleural effusion), as well as lymph edema of the lower extremities1-10. The diagnosis of YNS is established by two or three of the groups of manifestations, and the nail abnormalities may involve all digits and toes or spare some of them1-10. Pericardial or ocular changes may occur, and in 30% of cases, the triad is complete2; lymphedema is the first manifestation in approximately one-third of the YNS cases4. Familiar and acquired cases occur, but the etiopathogenesis is unclear; lymph vessel disorders, autoimmune phenomena, hypoalbuminemia, and drug effects are cited1-10. The YNS is more frequently reported in females, and occurring in all the age groups10.

Table 1 shows data of 10 Brazilian cases (90% women) of YNS, with an age range of 27–94 (mean: 73.8) years. Other changes were pincer (3) or half-and-half nails (1), and onychophagia/onychotyllomania (1); related disorders included renal failure (3), hypothyroidism (3), malignant tumors (2), Saint’s triad (1), and pericarditis (1)1-10.

Table 1. Brazilian case reports of yellow nail syndrome with associated conditions
References (years) Gender Age Associated disorders
Dos Santos et al.(2010)1 Female 61 Adnexal malignancy
Dos Santos et al.(2010)3 Male 85 Half-and-half nails and renal failure
Santos et al.(2013)5 Female 70 Onychophagia and Onychotyllomania
Santos et al.(2013)8 Female 86 Hypothyroidism
Santos et al.(2014)6 Female 78 Pincer nails
Dos Santos et al.(2015)2 Female 76 Pincer nails and colon malignancy
Modesto dos Santos
et al.(2015)4
Female 94 Renal failure
Santos et al.(2015)9 Female 72 Hypothyroidism and pericarditis
Santos et al.(2015)10 Female 89 Pincer nails and Saint’s triad
Santos et al.(2016)7 Female 27 Hypothyroidism and renal failure

Data extracted from ten Brazilian case studies published between 2010 and 2016

The comments, herein, included aim to emphasize the importance of the nails attentive evaluation during the complete physical examinations, to yield diagnostic clues. This applies both to dermatologists and to the majority of the other medical specialties.

Authors’ Contributions

The article has been drafted by both authors.

Conflicts of interest

None.

Ethics Approval and Consent to Participate

Not applicable.

Consent for Publication

Not applicable.

Financial Support and Sponsorship

None.

References

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