A month’s worth of terbinafine 250 mg/d did not improve the appearance of this 47-year-old woman's fifth fingernail and surrounding skin, so she was referred to dermatology. Affecting only this finger, the condition manifested slowly, several months ago, for no apparent reason. Fortunately, few if any symptoms have accompanied the changes—but the patient is quite upset nonetheless.
She denies any antecedent trauma to the finger and says it has not been excessively exposed to wetting and drying. She is otherwise in excellent health. Her only complaint about her health is mild seasonal allergies, along with sensitive skin (which manifested as eczema when she was a child).
EXAMINATION
The skin around the patient's right fifth fingernail is quite dry and scaly. It appears a bit inflamed, and there is visible separation between the cuticle and the adjacent nail plate. The nail itself is abnormal, with a rumpled, dystrophic surface on which transverse ridges are seen. No tenderness is elicited on palpation, nor can any pus be expressed from the subungual area. The rest of her fingernails and her toenails are unaffected.
Continue reading for Joe Monroe's discussion...