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Onycholysis Clinical Presentation

  • Author: Melanie S Hecker, MD, MBA; Chief Editor: William D James, MD  more...
Updated: Feb 09, 2016


Evaluation of patients with onycholysis requires a careful history of exposure to etiologic agents.



In onycholysis, nails are smooth, firm, and without inflammatory reaction.

Discoloration underneath the nail may occur as a result of secondary infection.

Spontaneous separation of the nail plate in onycholysis starts at the distal free margin and progresses proximally. Less often, nail plate separation may begin at the proximal nail and extend to the free edge. The nail plate is separated from underlying and/or lateral supporting structures.

Nail plate separation can be confined to the nail's lateral borders (rare).



Endogenous, exogenous, hereditary, and idiopathic factors can cause onycholysis. Contact irritants, trauma, and moisture are the most common causes of onycholysis, but other associations exist.

Endogenous factors in onycholysis

Systemic diseases and states in onycholysis are as follows:

  • Amyloid and multiple myeloma
  • Anemia (iron deficient)
  • Bronchiectasis
  • Diabetes mellitus
  • Erythropoietic porphyria
  • Histiocytosis X
  • Hyperthyroidism
  • Hypothyroidism
  • Ischemia (peripheral, impaired circulation)
  • Leprosy
  • Lupus erythematosus
  • Neuritis
  • Pellagra
  • Pemphigus vulgaris
  • Pleural effusion
  • Porphyria cutanea tarda
  • Pregnancy
  • Psoriatic arthritis
  • Reiter syndrome
  • Sarcoidosis
  • Scleroderma
  • Shell nail syndrome
  • Syphilis
  • Yellow nail syndrome

Dermatologic diseases in onycholysis are as follows:

Neoplastic disorders in onycholysis are as follows:

  • Squamous cell carcinoma (of nail bed)
  • Carcinoma (lung)

Exogenous factors in onycholysis

Nonmicrobial factors in onycholysis (may be encountered at the job site, ie, as occupational onycholysis) are as follows:

  • Mechanical - Mechanical force (trauma), repetitive minor trauma, or maceration
  • Chemical - Allergic contact dermatitis from various nail cosmetics (methyl methacrylate monomer, formaldehyde 1-2%, nail base coat/hardeners, polymerized 2-ethylcyanoacrylate adhesive used in artificial nails, nail lacquer), gasoline, paint removers, dicyanodiamide, thioglycolate, solvents, and hydroxylamine sulphate in color developer
  • Chemical - Irritant contact dermatitis from prolonged immersion of nails in water, sugar onycholysis in confectioners/bakers, and exposure to highly destructive toxins (eg, hydrofluoric acid)

Biologic/microbial factors are as follows:

  • Dermatophytosis (ie, Trichophyton rubrum, Trichophyton mentagrophytes infection)
  • Yeast ( Candida infection)
  • Bacteria ( Pseudomonas infection)
  • Virus (herpes simplex infection)

Drug associations with onycholysis

Photo-induced associations, with medication and subsequent exposure to sunlight, are as follows:

  • Tetracycline and its derivatives
  • Psoralens
  • Fluoroquinolones
  • Chloramphenicol
  • Benoxaprofen
  • Chlorpromazine
  • Chlortetracycline
  • Demethylchlortetracycline
  • Doxycycline [1, 2]
  • Minocycline
  • Oral contraceptives
  • 5-Methoxypsoralen (Psoraderm 5)
  • Aminolevulinic acid (from phototherapy) [3]
  • Olanzapine [4]
  • Aripiprazole [4]
  • Griseofulvin [5]

Photo-induced associations with onycholysis, without medication and exposure to sunlight, are as follows:

  • Spontaneous photo-onycholysis [6]
  • Bullous photo-onycholysis (during pseudoporphyria resulting from hemodialysis)

Non-photo–induced associations with onycholysis[7] are as follows:

  • Doxorubicin
  • Mitoxantrone
  • Captopril
  • Bleomycin
  • 5-Fluorouracil (capecitabine) [8, 9]
  • Retinoids
  • Tetracycline
  • Etoposide
  • Paclitaxel [10]
  • Docetaxel [10, 11]
  • Hydroxylamine

Other factors in onycholysis

These include the following:

  • Congenital onycholysis
  • Hereditary partial onycholysis
  • Idiopathic acquired onycholysis
  • Hereditary distal onycholysis [12]
  • Foreign body implantation
Contributor Information and Disclosures

Melanie S Hecker, MD, MBA President, Hecker Dermatology Group; Consulting Staff, Department of Dermatology, Imperial Point Medical Center, Holy Cross Hospital, and North Broward Hospital

Melanie S Hecker, MD, MBA is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, Medical Society of the State of New York

Disclosure: Nothing to disclose.


David Hecker, MD Consulting Staff, Dermatology Specialists of Palm Beach County

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD Associate Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Richard K Scher, MD Adjunct Professor of Dermatology, University of North Carolina at Chapel Hill School of Medicine; Professor Emeritus of Dermatology, Columbia University College of Physicians and Surgeons

Richard K Scher, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American Medical Association, Association of Military Surgeons of the US, International Society for Dermatologic Surgery, Noah Worcester Dermatological Society, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

  1. Passier A, Smits-van Herwaarden A, van Puijenbroek E. Photo-onycholysis associated with the use of doxycycline. BMJ. 2004 Jul 31. 329(7460):265. [Medline]. [Full Text].

  2. Rabar D, Combemale P, Peyron F. Doxycycline-induced photo-onycholysis. J Travel Med. 2004 Nov-Dec. 11(6):386-7. [Medline].

  3. Hanneken S, Wessendorf U, Neumann NJ. Photodynamic onycholysis: first report of photo-onycholysis after photodynamic therapy. Clin Exp Dermatol. 2008 Aug. 33(5):659-60. [Medline].

  4. Gregoriou S, Karagiorga T, Stratigos A, Volonakis K, Kontochristopoulos G, Rigopoulos D. Photo-onycholysis caused by olanzapine and aripiprazole. J Clin Psychopharmacol. 2008 Apr. 28(2):219-20. [Medline].

  5. Bentabet Dorbani I, Badri T, Benmously R, Fenniche S, Mokhtar I. Griseofulvin-induced photo-onycholysis. Presse Med. 2012 Jan 12. [Medline].

  6. Horio T. Spontaneous photo-onycholysis. J Dermatol. 1988 Dec. 15(6):540-2. [Medline].

  7. Makris A, Mortimer P, Powles TJ. Chemotherapy-induced onycholysis. Eur J Cancer. 1996 Feb. 32A(2):374-5. [Medline].

  8. Hogeling M, Howard J, Kanigsberg N, Finkelstein H. Onycholysis associated with capecitabine in patients with breast cancer. J Cutan Med Surg. 2008 Mar-Apr. 12(2):93-5. [Medline].

  9. Paravar T, Hymes SR. Longitudinal melanonychia induced by capecitabine. Dermatol Online J. 2009 Oct 15. 15(10):11. [Medline].

  10. Robert C, Sibaud V, Mateus C, Verschoore M, Charles C, Lanoy E, et al. Nail toxicities induced by systemic anticancer treatments. Lancet Oncol. 2015 Apr. 16(4):e181-e189. [Medline].

  11. Tinio P, Bershad S, Levitt JO. Medical Pearl: Docetaxel-induced onycholysis. J Am Acad Dermatol. 2005 Feb. 52(2):350-1. [Medline].

  12. Bazex J, Baran R, Monbrun F, Grigorieff-Larrue N, Marguery MC. Hereditary distal onycholysis--a case report. Clin Exp Dermatol. 1990 Mar. 15(2):146-8. [Medline].

  13. Oram Y, Karincaoglu Y, Koyuncu E, Kaharaman F. Pulsed Dye Laser in the Treatment of Nail Psoriasis. Dermatol Surg. 2010 Jan 19. [Medline].

  14. Edwards F, de Berker D. Nail psoriasis: clinical presentation and best practice recommendations. Drugs. 2009. 69(17):2351-61. [Medline].

  15. Scotte F, Banu E, Medioni J, et al. Matched case-control phase 2 study to evaluate the use of a frozen sock to prevent docetaxel-induced onycholysis and cutaneous toxicity of the foot. Cancer. 2008 Apr 1. 112(7):1625-31. [Medline].

  16. Scotte F, Tourani JM, Banu E, et al. Multicenter study of a frozen glove to prevent docetaxel-induced onycholysis and cutaneous toxicity of the hand. J Clin Oncol. 2005 Jul 1. 23(19):4424-9. [Medline].

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