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Clubbing of the Nails: Differential Diagnoses & Workup

Author: Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Coauthor(s): Gregory M Richards, MD, Staff Physician, Department of Human Oncology, University of Wisconsin School of Medicine and Public Health; Instructor of Radiotherapy Technology (RT 412), University of Wisconsin; Supriya Goyal, MD, Consulting Dermatologist
Contributor Information and Disclosures

Updated: Jun 12, 2009

Differential Diagnoses

Dermatologic Manifestations of Cardiac Disease
Dermatologic Manifestations of Gastrointestinal Disease
Dermatologic Manifestations of Hematologic Disease
Dermatologic Manifestations of Pulmonary Disease
Pachydermoperiostosis

Other Problems to Be Considered

Hypertrophic osteoarthropathy is a syndrome defined by chronic proliferative periostitis of the long bones, digital clubbing, and joint swelling.

Pseudoclubbing is defined as an overcurvature of the nails in both the longitudinal and transverse axes, with preservation of a normal Lovibond angle.

Workup

Laboratory Studies

  • Because clubbing typically is secondary to an underlying pathological process, perform pertinent laboratory studies for primary medical disorders that are suggested clinically.

Imaging Studies

  • Radiographic changes in patients with digital clubbing vary and include bone dissolution, bone formation, or no change in the bone of the distal phalanx. The types of changes may depend on the underlying pathological processes, as well as the duration of the processes. The severity of soft tissue changes in clubbed digits has not been found to correlate with the type of bone change or the degree of radiographic change. Probably, the lysis of bone predominates in the digits of patients with congenital cyanotic heart disease, while hypertrophy predominates in the digits of patients with clubbing secondary to pulmonary conditions. As an alternate view, hypertrophy may occur earlier in the process of clubbing, and, eventually, it may change to osteolysis as the process becomes chronic.
  • Technetium Tc 99m skeletal imaging with good-quality views may be helpful in determining the presence and extent of bone changes in clubbed digits, which show increased uptake of the radionuclide. The increased, intense, symmetric uptake typically is localized to the nail beds and may result from increased blood flow and changes in the surrounding soft tissues.
  • Thermography is another imaging modality being studied for use in diagnosis and monitoring of patients with digital clubbing.24 Patients may show increased temperature in the distal digits, which can be attributed to an increase in blood flow secondary to vasodilation. Not all patients with clubbing have positive thermographic results.
  • Positron emission tomography also has been used to study the glucose metabolism of clubbed digits.25 An increased signal, indicating increased glucose metabolism, has been demonstrated in the distal part of the clubbed fingers. These changes are not seen in fingertips with normal morphology. The increase in signal supports the theory that clubbing is caused by the presence of a factor (eg, platelet-derived growth factor) that increases cellular metabolism.
  • Other imaging studies, such as computed tomography or magnetic resonance imaging, may be helpful in evaluating the patient for the primary pathological process causing the clubbing.

Histologic Findings

Microscopically, the collagen fibrils and cells are separated by a distance greater than that seen in histologically normal specimens. This increased separation results in a less dense nail bed matrix. Primitive fibroblasts are seen with large nuclei, basophilic cytoplasm, and long reticular processes. Increased and scattered extravascular lymphocytes and, less often, a moderately increased number of tissue eosinophils also are noted in the nail beds of some specimens. The periosteum of the nail bed may be thickened with increased vascular penetration.

Eventually, increased collagen is laid down in all types of chronic clubbing. The mat of collagen fibers may be abnormally thick and dense. The walls of the vascular components increase in thickness and are encased in a thick fibrous sheet. At this stage of clubbing, the histologic and morphologic changes probably are irreversible.

More on Clubbing of the Nails

Overview: Clubbing of the Nails
Differential Diagnoses & Workup: Clubbing of the Nails
Treatment & Medication: Clubbing of the Nails
Follow-up: Clubbing of the Nails
Multimedia: Clubbing of the Nails
References
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References

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Further Reading

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Keywords

hippocratic nails, hippocratic fingers, acropachy, dysacromelia, Trommelschlegelfinger, clubbing, digital clubbing, finger clubbing

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Contributor Information and Disclosures

Author

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Gregory M Richards, MD, Staff Physician, Department of Human Oncology, University of Wisconsin School of Medicine and Public Health; Instructor of Radiotherapy Technology (RT 412), University of Wisconsin
Gregory M Richards, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Medical Association, American Roentgen Ray Society, American Society of Clinical Oncology, American Society of Therapeutic Radiation Oncology, and Radiological Society of North America
Disclosure: Nothing to disclose.

Supriya Goyal, MD, Consulting Dermatologist
Supriya Goyal, MD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Nothing to disclose.

Medical Editor

Richard K Scher, MD, Professor of Dermatology, University of North Carolina
Richard K Scher, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Cryosurgery, American College of Physicians, American Dermatological Association, American Geriatrics Society, American Medical Association, Association of Military Surgeons of the US, International Society for Dermatologic Surgery, New York Academy of Sciences, Noah Worcester Dermatological Society, Rhode Island Medical Society, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Warren R Heymann, MD, Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey
Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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