HMCL312 www.endeavour.edu.au Session 8 Nail signs
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HMCL312
www.endeavour.edu.au
Session 8
Nail signs
© Endeavour College of Natural Health www.endeavour.edu.au 2
SN08 Overview
Nutrient deficiency and disease associated Nail Diagnosis
Pre-Assessment Considerations:
o Working hypothesis of the pattern of disturbance
o Differential diagnoses
o Duty of care
o Medical ‘Red Flags’ - referral
© Endeavour College of Natural Health www.endeavour.edu.au 3
Nail assessment
In the clinical setting, the nails provides a quick, easily accessible and non-
invasive means of assessment. In the context of Objective data, nails can
indicate overall health of the client and guide towards further questioning and
investigations. In general they give information about:
o Dietary intake
o Digestive absorption
o Blood flow
o Nutritive value of the blood
© Endeavour College of Natural Health www.endeavour.edu.au 4
Common Causes of Nail Abnormalities
o Abnormalities in the colour,
shape, texture, size or thickness
of the nails are often the result of
either injury, infection, disease,
poisoning, nutritional deficiency
or genetic pre-disposition, and
can provide many clues as to
underlying systemic disease
long before other symptoms
arise
nailmag.com
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Nail Diagnosis
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Common Nail SignsSign Deficiency
Splitting, fraying,
chipping, peeling, easily
broken
Vitamin A, C, D, calcium, protein intake and absorption, poor diet and malnutrition.
Thinning and Softening Vitamin C, B12, protein intake and absorption, poor diet and malnutrition.
Horizontal Grooving or
Ridging
Protein intake and absorption, poor diet and malnutrition.
Vertical Grooving or
Ridging
Vitamin A, calcium, iron, silica, protein intake and
absorption.
Brittleness Iron
Spooning/koilonychia Iron deficiency (Mahan and Escott-Stump, 2008)
© Endeavour College of Natural Health www.endeavour.edu.au 7
Nutritional Deficiency
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Splitting
Just.health.com
Vitamin A, C, D, calcium, protein intake and
absorption, poor diet and malnutrition.
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Thinning & Softening
o Vitamin C, B12, protein intake and absorption, poor diet and malnutrition.
postitvmed.com
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Horizontal Grooving or Ridging
o Protein intake and absorption, poor diet
and malnutrition. Also signs of a systemic
illness or trauma (Beaus Ridges.)
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Transverse Depressions (Beau’s Ridges)
o Interruption in protein formation and nail growth
which often follows local trauma about one month
after the event
o Can occur after illness, or major metabolic condition
o May reflect poor nutritional status, febrile illness, or a
reaction to medication, Chemotherapy or other
damaging event
o May indicate malnutrition
o Exposure to cold temperatures in patients with
Raynaud's disease
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Vertical Grooving or Ridging
o Vitamin A, calcium,
iron, silica, protein
intake and
absorption.
buzzle.com
handresearch.com
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Vertical striations
o Alopecia areata, vitiligo, atopic dermatitis, psoriasis, splinter haemorrhage
o Subacute bacterial endocarditis
o SLE
o Rheumatoid arthritis
o Antiphospholipid syndrome
o Peptic ulcer disease
o Malignancies
o Oral contraceptive pill
o Pregnancy
o Ageing
© Endeavour College of Natural Health www.endeavour.edu.au 14
Vertical (Longitudinal) Ridging
o Poor absorption of EFA's, Vitamins and Minerals (Iron,
Silica); Thyroid dysfunction; Kidney failure
o May indicate a tendency to arthritis
o Occur in some patients with rheumatoid arthritis,
peripheral vascular disease, lichen planus, or Darier's
disease
o Longitudinal red/white striations invariably occur with
Darier's disease, and V-shaped notching or nicking of the
free edges of the nails are also common
© Endeavour College of Natural Health www.endeavour.edu.au 15
Darier's Disease
o V-shaped nicking and red/white longitudinal striations of Darier's disease
© Endeavour College of Natural Health www.endeavour.edu.au 16
Brittleness
handresearch.com
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Koilonychia
o Koilonychia is associated with
chronic iron deficiency anaemia
It has even been reported in
haemo- chromatosis.
o It can be a normal finding in
infants and resolves within the
first 18-24 months of life.
handresearch.com
© Endeavour College of Natural Health www.endeavour.edu.au 18
Spooning or Concavity
o Associated with iron-deficiency anaemia and Plummer-Vinson
syndrome, as a result of thinning and softening of the nail plate
o Spoon-shaped nails are a normal, physiologic occurrence in
children and tend to resolve, either with treatment or with
ageing
o Indicate deficiency of iron, protein (especially sulphur
containing amino acids)
o Possible precursor to haemochromatosis
o Raynaud's disease; SLE
© Endeavour College of Natural Health www.endeavour.edu.au 19
Spooning or Concavity
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Brief case scenario:
o A client presents with digestive problems (cramping and bloating after meals)
and a largely takeaway vegetarian based diet. Additionally she has heavy
menstrual bleeding and has been feeling very fatigued for several months.
o What appearance would you expect her nails to have? What deficiency is it
most likely indicative of? How long might she have had this deficiency?
© Endeavour College of Natural Health www.endeavour.edu.au 21
Pitting (punctate depressions)
o Punctate depressions in the nail plate, sometimes with
yellow or brown ‘oil’ spots
o The pits represent abnormal keratinisation in the nail
matrix
o Indication of connective tissue disorders
o Most commonly occurs with psoriasis, less so with
alopecia areata and eczema
o Reiter's syndrome
o Sarcoidosis
o Pemphigus
o Alopecia areata (Fawcett et al, 2004)
© Endeavour College of Natural Health www.endeavour.edu.au 22
Pitting
(punctate depressions)
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Brief case scenario:
A 75 year old client presents with long term reflux and arthritis that she
manages with pain killers, the most recent of which is Panadol-Osteo which she
finds helpful. On review, her diet is very refined and deficient of many nutrients,
especially essential fatty acids.
What would you anticipate her nails might be like? What kind of nail signs?
What nutrients or dietary changes would you suggest to improve her nails (and
her overall health)?
© Endeavour College of Natural Health www.endeavour.edu.au 24
Nail signs indicative of Nutritional Deficiency
Sign Deficiency
White Spots Vitamin A, calcium, zinc (Bakan,
1990)
Paleness or
whitening
Iron, B12, Folic Acid, protein intake
and absorption.
Yellowing Vitamin E
Darkening or
blackening
Vitamin B12
Pitted red-brown
spot
Vitamin C
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White Spots
o Vitamin A,
o calcium, zinc o (Bakan 1990)
nailsmag.com
examiner.com
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Paleness or whitening
o Iron, B12, Folic
Acid, protein
intake and
absorption.
www.tti.library.tcu.edu.tw/DERMATOLOGY/na/na0023f.htm
www.tti.library.tcu.edu.tw/DERMATOLOGY/na/na0025f.htm
© Endeavour College of Natural Health www.endeavour.edu.au 27
White Nail
o White, Crumbly and Soft
o May be fungal infection
o White with red at the tips
o Cirrhosis of the liver;
o Kidney disorders
o Anaemia
o Fungal infection
© Endeavour College of Natural Health www.endeavour.edu.au 28
White Nailo Unusual whitening of the nail plate where the lunula may be
obliterated, may result from:
o Liver disease (Cirrhosis).
o Kidney dysfunction
o Diabetes mellitus
o Heart Disease
o Hyperthyroidism
o Anaemia
o Arsenic poisoning
o Renal failure
o Pneumonia
o Hypo-albuminaemia
Malnutrition
© Endeavour College of Natural Health www.endeavour.edu.au 29
Muehrcke's Lines
(pairs of transverse white lines)o Interruption of pigmentation
(Specific for hypo-
albuminaemia)
o May disappear when
protein levels normalise
o May also indicate Kidney
disease
o Liver disease
o Malnutrition
o Chemotherapy
(Fawcett et al, 2004)
© Endeavour College of Natural Health www.endeavour.edu.au 30
Mees' lines (Aldrich-Mees' lines)
o Single transverse white line
o Heavy metal poisoning
o Sign of ‘interrupted’ metabolic
activity;
o Hodgkin's disease
o Congestive Heart Failure
o Malaria
o Chemotherapy
o Carbon monoxide poisoning
o Renal failure. (Fawcett et al, 2004)
© Endeavour College of Natural Health www.endeavour.edu.au 31
Yellowing
o Usually associated with
Lymphedema & Respiratory
tract disorders (Tosti & Piraccini, 2000)
o Pulmonary disorders (e.g.
Bronchiectasis, Tuberculosis,
Pleural Effusion)
o Lymphatic dysfunction
(Lymphoedema, especially of
the ankles)
o Rheumatoid arthritis
o Renal disease (Nephrotic
syndrome)
© Endeavour College of Natural Health www.endeavour.edu.au 32
Yellowing
o Immuno-deficiency
o Vitamin E deficiency
o Thyroiditis
o Raynaud's disease
o Liver dysfunction
o Fungal infection
o Psoriasis
© Endeavour College of Natural Health www.endeavour.edu.au 33
Yellow Tips
o Liver problems
o Melanoma
o Digestive disturbances
o Smoker
o Tetracycline.
o Rx = Oral Vitamin E at doses 600-1200 IU daily for
6-12mths may induce complete clearing of nail
changes (Tosti & Piraccini, 2000)
© Endeavour College of Natural Health www.endeavour.edu.au 34
Green
o Pseudomonas
o Candidiasis
o Bacillus infection
o Localized fungal infection
o Allergies to cleaning agent
o Serious emphysema
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Pitted red-brown spot
o Pitted red-brown spots
o May indicate psoriasis
o Deficiency of folic acid, protein and/or Vitamin C
www.medscape.com.
Red Nail
o Red Bands at the Tips(Terry’s Nails)
o Liver disease
o Renal disease
o Redness of the lunula
o Excess of RBC
o Heart disease
o Collagen vascular disease
o Haematological malignancy
o Tetracycline therapy
www.medscape.com
© Endeavour College of Natural Health www.endeavour.edu.au 37
Grey
o Arthritis
o Oedema
o Malnutrition
o Post-operative effects
o Glaucoma
o Cardio-pulmonary
disease www.health-network.co.uk
© Endeavour College of Natural Health www.endeavour.edu.au 38
Blue or Blue-Grey Nails
o Blue or Deep Blue:
o Indicates poor oxygenation of the blood
o Lupus erythematosus/ RA
o Liver disease (Hepatitis)
o Kidney disease
o Copper or silver poisoning
o Anaemia (Decreased haemoglobin)
o Increased inflammation
o Cholesterol Fawcett et al, 2004)
© Endeavour College of Natural Health www.endeavour.edu.au 39
Blue, Purple, Black Nails
o Blue, Purple & Black
o Usually due to trauma
o May be a sign of vitamin B12 deficiency
o Oxygen deprivation
o Circulatory problems
o Congenital disorder
o Blue or ‘azure’ lunula
o May indicate Wilson’s Disease (Hepatolenticular degeneration)
o Quinacrine therapy
o Pulmonary disease
o Silver poisoning
© Endeavour College of Natural Health www.endeavour.edu.au 40
Darkening Browno Browning
o Excessive fluoride ingestion; Arsenic or copper poisoning;
Fungal infection
o Brown discoloration that has spread to the surrounding
tissue could indicate gastro-intestinal polyps or malignant
melanoma
o Pitted brown spots or splits fingernail tips
o May indicate psoriasis
o Brown Spots are typically a sign of infection (Fungal)
o Dark nails that are flat and/or thin
o Indicate vitamin B(12) deficiency
o Dark pigment on distal nail:Drug-induced (Phenothiazines)
© Endeavour College of Natural Health www.endeavour.edu.au 41
Darkening or blackening
o Vitamin B12
schaltzie-speaks.hubpages.com
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Darkening Black
o Blackening or Darkening
o Excessive fluoride ingestion
o Heavy metal poisoning (Silver)
o Anaemia
o B-12 deficiency
o Bacterial infection
o Kidney disease
o Adrenal gland problems
o Liver disease
o Cancer or melanoma
o Trauma
© Endeavour College of Natural Health www.endeavour.edu.au 43
Darkening Black
o Black Spots
o Typically a sign of infection
o Any black discolouration that has spread to the surrounding tissue could indicate gastro-intestinal polyps or malignant melanoma
www.medscape.com
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Longitudinal Melanonychia
o Black discoloration of the proximal nail fold at the base of the
pigmented streak (Hutchinson's sign) is a sign for melanoma
o Longitudinal melanonychia in one nail without an obvious
explanation warrants a biopsy of the nail matrix. Melanoma of
the nail unit has a poor prognosis
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Half White & Half Brown Nails
o Renal disease
o Increased melanin
production
(Fawcett et al, 2004)
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Onychomycosis (Tinea unguium)
o A fungal or yeast infection of the nail, usually caused by Tinea rubrum,
T. mentagrophytes, or Candida albicans;
o Most common nail disorder!
o Predisposing factors for infection include immune problems, heat,
moisture, trauma, diabetes mellitus, and tinea pedis
o Affected nails are dystrophic and hyperkeratotic (thickened), often
with yellow-brown discoloration
© Endeavour College of Natural Health www.endeavour.edu.au 47
Onychomycosis (Tinea unguium)
o Treatment can be symptomatic, frequently with the aid of a podiatrist for
toenail onychomycosis. If warranted, systemic treatment involves the use of
either terbinafine or itraconazole (Success with either agent is less than 50%,
and recurrences are common)
http://www.dermnetnz.org/fungal/candida.html
SOURCE: CDC/Dr. Edwin P. Ewing, Jr.
© Endeavour College of Natural Health www.endeavour.edu.au 48
Nail Plate Separation (Onycholysis)
o It can be caused by any local problem, such as periungual
warts or onychomycosis
o In patients with hyperthyroidism, onycholysis is known as
‘Plummer's nails’
o Hyperthyroidism also can cause brown discoloration of the
nail plate
o Psoriasis
o In the absence of trauma or psoriasis, onycholysis should
prompt a search for symptoms of hyperthyroidism
o Anaemia
© Endeavour College of Natural Health www.endeavour.edu.au 49
Nail Plate Separation (Onycholysis)
o Fungal, Yeast or Bacterial Infections
o Medications, Drugs (e.g. Tetracycline)
o Chemotherapy
o Raynaud’s disease
o SLE
o Thyrotoxicosis
o Hyperthyroidism
o Amyloidosis
o Sarcoidosis and other connective tissue disorders
© Endeavour College of Natural Health www.endeavour.edu.au 50
Nail Plate Separation
o Onycholysis may accompany psoriasis, when the
distal portion of the nail matrix is affected
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Psoriasiso Characterised by raw, scaly skin and is sometimes
confused with eczema
o When it attacks the nail plate, it will leave it pitted, dry,
and it will often crumble. The plate may separate from the
nail bed and may also appear red, orange or brown, with
red spots in the lunula
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Thickened Nails
o Unusually thick nails: may be the result of internal disorders
o May indicate a weakening of the vascular system, with
circulatory problems
o Fungal infections
o Heredity
o Mild, persistent trauma to the nail
© Endeavour College of Natural Health www.endeavour.edu.au 53
Nail Hematoma
o The result of trauma to the nail
plate, such as trapping your
finger in the car door or hitting
the fingernail with a hammer
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Pterygium of Nail
o An inward advance of skin over the nail plate
o Usually the result of trauma to the matrix due to a surgical procedure, or by a
deep cut to the nail plate
o Pterygium results in the loss of the nail plate due to the development of scar
tissue
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In-grown Toenail (Onychogryposis)
o Claw-type nails, characterised by a thickened nail plate and
often the result of trauma
o Often require surgical intervention to relieve the pain
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Clubbing
o Clubbing is one example of a nail manifestation of systemic disease
and was first described by Hippocrates in the fifth century B.C., and
may indicate
o Pulmonary Disease, including Bronchiectasis, Bronchitis, Lung
abscess, Empyema, Pulmonary Fibrosis, Cystic Fibrosis,
Asbestosis, Malignancy
o Cirrhosis of the Liver
o Cardiac Disease, such as Congenital Heart Disease, Endocarditis,
Atrioventricular malformations, Fistulas
o GIT Diseases, such as: Coeliac Disease, Ulcerative Colitis or
Inflammatory Bowel Disease
o Hyperthyroidism
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Clubbing
o The finding of clubbing without obvious associated disease
should prompt a search for bronchial or cardiac disease
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Splinter Haemorrhage
o This sign often follows
trauma to the nail
o If no trauma, look for
bacterial endocarditis
o They may resolve,
recur, or persist
(Fawcett et al, 2004)
o Possible indication of
vitamin C deficiency
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Verruca Vulgaris (Warts)
o Warts, or verruca vulgaris, are an infection of the proximal and
lateral nail folds
o The human papilloma virus (HPV), types 1, 2, and 4 are primarily
responsible
o Because of the location, these warts are particularly difficult to
treat, especially if they extend subungually
o Subungual warts may cause deformity or discoloration of the nail
plate
o Affected patients are often
‘nail biters’
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Paronychia Infection
o Can be caused by a
number of bacteria, fungi,
yeast and viruses
o Usually staphylococcus,
streptococcus or candidiasis
infection
© Endeavour College of Natural Health www.endeavour.edu.au 61
Acute Paronychia
o Inflammation of the proximal and lateral nail folds
characterised by erythema, oedema, and pain
o Purulent drainage with compression behind the cuticle may
also occur
o Trauma is often the initial event with secondary infection with
Staphylococcus aureus
or Streptococcus pyogenes
o Treatment usually requires
compresses and an oral
anti-staphylococcal antibiotic
© Endeavour College of Natural Health www.endeavour.edu.au 62
Chronic Paronychia
o Usually a non-infectious disease that
follows irritant or allergic contact
dermatitis of the proximal nail fold
o The cuticle is invariably absent
o Affected individuals often trim the
cuticles aggressively, or do ‘wet work’
with their hands
o Secondary infection with Candida
albicans is common
o Treatment involves aeration, and a
topical and/or oral antifungal agent
© Endeavour College of Natural Health www.endeavour.edu.au 63
Tinea Unguis
(Ringworm of the nails)
o Fungal infection, characterised by nail thickening, deformity, and eventually
results in nail plate loss.
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Squamous Cell Carcinoma (SCC)
o The most common malignancy of the nail
unit
o SCC is usually a verrucal (warty) plaque
on the lateral nail fold of the finger, and
may resemble a wart unresponsive to
traditional therapy
o SCC is associated with HPV-16 infection
and less so with trauma and radiation
o SCC of the nail unit grows
slowly and metastasis is rare
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Melanonychia(vertical pigmented bands)
o Described as nail 'moles' which usually
form in the nail matrix
o Could signify malignant melanoma or
lesion
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Other Nail Considerations
o Over-Sized Moons:
o Overactive thyroid;
o Genetics;
o Self-induced trauma
o No Moons:
o Under-active thyroid;
o Genetics.
www.health-boundaries.com/fingernails-linesridges
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Pre-assessment Considerations
Having gathered information about the patient (both subjective &
objective) the next step in the Naturopathic consultation process
involves analysing the various information and putting into some
form of perspective
Considerations prior to formulating an assessment of the patient
should include:
• Working hypothesis of the pattern of disturbance
• Differential diagnosis
• Rule-ins/rule-outs
• Medical Red Flags – need for referral?
• Duty of care/scope of practice
© Endeavour College of Natural Health endeavour.edu.au 68
Pattern of Disturbance
Via the process of gathering patient information the Naturopath begins to
formulate an impression of what is going on with the patient (their pattern of
disturbance).
This impression is formed from information relating to the physical,
mental/psychological, emotional & “spiritual” aspects of the patient and their
health condition.
Where a biomedical practitioner aims to identify/diagnose a disease entity so
that the specific pathophysiology can be determined and treated, the
Naturopath looks to understand:
• the pattern of disturbance;
• the disturbing factors/obstacles to cure;
• the process of disease/health (is the condition acute/sub-
acute/chronic/degenerative).
© Endeavour College of Natural Health endeavour.edu.au 69
Analysing the Pattern of Disturbance
• Is there a central theme or a “weak link” in the patient’s life that has
led to their current condition of health?
• What are the contributing or disturbing factors to the patient’s
condition?
• At this present time, what are the driving factors in the patient’s health
condition?
• What tissues, organs, systems are affected?
• What degenerative processes are at play currently?
• What regenerative processes are at play currently?
© Endeavour College of Natural Health endeavour.edu.au 70
The Mind Map and the Timeline of Health are useful tools for
assisting to formulate an impression of the patient’s pattern of
disturbance
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Tutorial
Review the Tutorial Case provided, develop a mind map and
treatment strategy for the case. Consider prioritising treatment,
differential diagnosis, further investigations needed, long and short
term goals and treatment plan options.
Apply holistic principles to your case understanding.
If time allows look at the other case studies and apply the same
considerations
Handout Cases 1, 2, 3, 4
© Endeavour College of Natural Health www.endeavour.edu.au 72
Tutorial
Tongue and nail assessment on a partner
1. Chose a partner and conduct a Nail and Tongue assessment.
2. Explain Nail and Tongue assessment to your partner and let them know what
you plan to do.
3. In easy to understand terms describe to your partner your findings. Imagine
that they are a first appointment client.
4. Now allow your partner to give you feedback on your Nail and Tongue
assessment skills and also how they felt with your explanation and account of
your findings on their tongue and nail appearance.
© Endeavour College of Natural Health www.endeavour.edu.au 73
Bibliography1. Yale, S. and La Valle, J.B. (2002). Food Allergies and Atopic Dermatitis. Alternative & Complementary
Therapies.
2. Sebrell, W. H. (1945). Deficiency Diseases in General Practice. Southern Medical Journal, 39 (3), pp:265-68
3. Poole, W. L. (1957). Effect of Vitamin B Complex and S-Factor on Acne Rosacea. Southern Medical Journal, 50 (2), pp:207-210
4. Majamaa, H., Miettinen, A., Laine, S., Isolauri, E. (1995) Intestinal inflammation in children with atopic eczema: faecal eosinophil cationic protein and tumour necrosis factor-a as non-invasive indicators of food allergy. Clinical & Experimental Allergy, 26 (2), pp:181-187
5. Proksch, E., Folster-Holst, R., Jensen, J. M. (2006) Skin barrier function, epidermal proliferation and differentiation in eczema. Journal of Dermatological Science, 43 pp: 159-169
6. Heath, ML., Sidbury, R. (2006) Cutaneous manifestations of nutritional deficiency, Current Opinion in Pediatrics, Vol 18 (4), pp:417-422
7. Fawcett, R. S., Linford, S., Stulberg, D. L. (2004) Nail abnormalities: clues to systemic disease, American Family Physician, 69 (6) pp: 1417-1424
8. Tosti, A., Piraccini, B. M. (2000). Treatment of Common Nail Disorders, Dermatologic Clinics. 18 (2)
9. Field, A. E., Speechley, J. A., Rugman F. R., Varga, E., Tyldesley, WR. (1995). Oral signs and symptoms in patients with undiagnosed vitamin B12 deficiency, Journal of Oral Pathology and Medicine, 24, p:468-470
10. Marks, R and Simons, M. J. (1979). Geographic tongue – a manifestation of atopy. British Journal of
Dermatology, 101, pp:159-162
11. Rogers, RS and Bruce, A. J. (2004). The tongue in clinical diagnosis, European Academy of dermatology
and Venerology, 18, pp:254-259
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Bibliography12. Jansen, A.J. and Bailey, K.V. (1977). The early detection of childhood malnutrition in the south pacific, J
Trop Pediatr, Vol 23, pp: 125-137
13. Femiano, F. (2001). Geographic tongue (migrant glossitis) and psoriasis, Minerva Stomatol, Vol 50 (6)
pp:213-7
14. Smith, C and Song, W. (1996). Comparative nutrition of pantothenic acid, The Journal of Nutritional
Biochemistry, Vol 7 (6), pp:312-21
15. Areekul, S., Panatampon, P. and Doungbarn, J. (1977.) Vitamin B12 and vitamin B12 binding proteins in
liver diseases, Southeast Asian J Trop Med Public Health, Vol 8 (3) pp:322-8
16. Barthelemy, H., Chouvet, B., Cambazard, F. (1986) Skin and mucosal manifestations in vitamin
deficiency, J Am Acad Dermatology, Vol 15 (6) pp:1263-74
17. Predniville, J.S and Manfredi, L.N. (1992). Skin signs of nutritional disorders, Seminars in Dermatology,
11 (1) pp: 88-97
18. JAE-YOUNG UM et al. (2004). Association Between Iris Constitution and Apolipoprotein E Gene
Polymorphism in Hypertensives, The Journal of Alternative and complementary medicine, 10 (6)
pp: 1101-05
19. Taher, Q et al (2004) Nutritional Kiolonychia in 32 Iraqi subjects, Annual Saudi Medicine, Vol 25 (2) pp:
154-157
20. just.health.com
21. www.medscape.com
22. www.health-boundaries.com/fingernails-linesridges
23. Tully, A.S, Trayes, K.P, Studdiford, J. (2012). American Family Physician, Evaluation of nail abnormalities.
85(8):779-87. https://www.ncbi.nlm.nih.gov/pubmed/22534387
© Endeavour College of Natural Health www.endeavour.edu.au 75
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