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Comment on "Terry's nail: an overlooked physical finding in cirrhosis"

To the Editor:

We read with great interest the recent paper by Baran and colleagues,[1]published in the journal ofHepatobiliary Pancreatic Diseases International. The authors presented nails abnormalities in a 65-year-old woman with cryptogenic cirrhosis and hepatocellular carcinoma and described them as Terry's nails. Whether they were Terry's nails remains controversial, at least far away from the typical Terry's nails. Thus we have several comments with respect to the photograph.

First, fully developed Terry's nails exhibit a groundglass-like opacity of almost the entire nail bed. The condition is bilaterally symmetrical, with a tendency to be more marked in the thumb and forefinger (Fig. A).[2]However, the white discoloration of proximal nails is inhomogenous in their images, and red nail bed is noted in all left fingernails and in forefinger and little finger of right hand.

Second, another classical presentation of Terry's nails is a distal thin brown to pink transverse band of 0.5-2.0 mm in width (Fig. A).[2]Although the authors described a zone of normal pink at the distal edge of the nails, only forefinger, middle and ring finger of right hand in their images have a pink transverse band with fuzzy boundaries in width of 4-6 mm and occupy 20% to 40% of the nail length. These abnormalities need to differentiate from half-and-half nails, which are typically seen in chronic renal failure, as well as in cirrhotic patients with severe hypoalbuminemia.[3]

Nail abnormalities can be a revealing sign of a systemic disease including liver cirrhosis. The most common nail abnormality in patients with liver cirrhosis is Terry's nails. Terry's toenails also can occur in cirrhotic patients (Fig. B). Classical presentation of Terry's nails or toenails included a distal thin brown to pink transverse band of 0.5-2.0 mm in width, white nail bed, and absence of the lunula.[2,4]Although Terry's nails are only a visual diagnosis and validated diagnostic criteria are absent, and some patients with Terry's fingernails show inhomogeneous changes in all nails in a random fashion,[5]the readers of the journal would be happier with a more classical presentation of this condition.

Zheng-Xiao Li and Sheng-Xiang Xiao Department of Dermatology and Venereology, Second Affiliated Hospital, College of Medicine, Xi'an Jiaotong University, Xi'an 710004, China

Fan-Pu Ji

Department of Infectious Diseases, Second Affiliated Hospital, College of Medicine, Xi'an Jiaotong University, Xi'an 710004, China

Email: jifanpu1979@163.com

1 Baran B, Soyer OM, Karaca C. Terry's nail: an overlooked physical finding in cirrhosis. Hepatobiliary Pancreat Dis Int 2013;12:109.

2 Terry R. White nails in hepatic cirrhosis. Lancet 1954;266:757-759.

3 Lindsay PG. The half-and-half nail. Arch Intern Med 1967; 119:583-587.

4 Li Z, Ji F, Deng H. Terry's nails. Braz J Infect Dis 2012;16:311-312.

5 Albuquerque A, Sarmento J, Macedo G. Hepatobiliary and pancreatic: Terry's nails and liver disease. J Gastroenterol Hepatol 2012;27:1539.

Published online March 27, 2014.

Fig.Terry's nails and toenails associated with cirrhosis. The white nail bed, a distal thin pink transverse band of 1.5 mm in width and loss of lunula.

The Author Reply:

We thank the authors for their commentary on our paper[1]and providing the high quality clinical image. The authors described a classic case of a cirrhotic patient with fully developed Terry's nails.[2]They mentioned that fully developed Terry's nails exhibit a ground-glasslike opacity of the nail bed with a distal thin brown topink transverse band. However, nail changes in systemic diseases develop as a process, and not all patients exhibit exactly the same appearance. Terry's nails are a spectrum of nail changes, and the appearance may be variable at different stages in each finger,[3]as the authors also mentioned. The authors expressed our photograph differently, but we disagree with their interpretation at some points. The initial criteria for diagnosis of Terry's nails were modified in a later report, and the condition was defined as a distal brown or pink band up 3 mm wide which is the earliest sign and caused by telangiectasia in the upper dermis of the nail bed. The pallor of the proximal nail seems to develop gradually later in the process of nail changes.[4]In our case, the proximal parts of fingernails were pale with a loss of lunula and there were normal pink colour of 3 mm width at the distal edge of the nails. At several fingers, the red nail bed extended a few millimeters proximally only in the middle of the nail, as we described in the paper. In patients with chronic renal failure or hypoalbuminemia, increased melanin production may cause the distal part of the nail bed to turn brown which is called also as half-and-half nails (Lindsay's nails).[5]There is significant overlap between Terry's nails and half-and-half nails and therefore precise differentiation of these nail abnormalities can be difficult without clinical information.[6]Some authors prefer to describe the nail abnormality in chronic liver disease as Terry's half-and-half nails in this context. Although we could not detail in the paper due to the word limit, in our case the decompensation was due to recent development of ascites and the patient did not have renal insufficiency or hypoalbuminemia which makes Lindsay's nails highly unlikely.

Bulent Baran, MD, FEBG, Department of Gastroenterology, Van Training and Research Hospital, Van 65300, Turkey

Email: drbulentbaran@gmail.com

References

1 Baran B, Soyer OM, Karaca C. Terry's nail: an overlooked physical finding in cirrhosis. Hepatobiliary Pancreat Dis Int 2013;12:109.

2 Terry R. White nails in hepatic cirrhosis. Lancet 1954;266:757-759.

3 Albuquerque A, Sarmento J, Macedo G. Hepatobiliary and pancreatic: Terry's nails and liver disease. J Gastroenterol Hepatol 2012;27:1539.

4 Holzberg M, Walker HK. Terry's nails: revised definition and new correlations. Lancet 1984;1:896-899.

5 Lindsay PG. The half-and-half nail. Arch Intern Med 1967;119:583-587.

6 Fawcett RS, Linford S, Stulberg DL. Nail abnormalities: clues to systemic disease. Am Fam Physician 2004;69:1417-1424.

(doi: 10.1016/S1499-3872(14)60051-5)

Published online March 27, 2014.

10.1016/S1499-3872(14)60050-3)