Muehrcke Lines of the Fingernails Clinical Presentation

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD   more...
 
Updated: May 9, 2011
 

History

Muehrcke lines of the fingernails is a transverse leukonychia.[25] A complete and detailed history is necessary and should include questions concerning occupation and medications. Attention to the chronologic sequence of the events related to the nail abnormality is important. The personal history and a review of systems may also provide important clues to the etiology of the nail changes.

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Physical

The 2 transverse bands originally described by Muehrcke run parallel to the lunule. The bands are separated from each other and from the lunule by areas of normal pink nail, they are not palpable, and they do not indent the nail itself. The distal white band may be wider than the proximal band. The lines are usually found on the second, third, and fourth fingernails; they rarely occur on the thumbnail.[1] The lines are more pronounced with severe and prolonged hypoalbuminemia, and in some patients, they can be reduced or eliminated by intravenous administration of salt-poor serum albumin. They may also be seen following chemotherapy and constitute an aesthetically unpleasant adverse effect of medication and an easily observed sign indicative of previous use of cytotoxic therapy for malignancy.[25]

The physical examination of the nails is valuable in providing clues to the etiology of the nail abnormality. Therefore, a detailed and efficient examination of the nails, in addition to an examination of the rest of the skin and mucous membranes, is essential. Perform a complete physical examination if indicated.

Daniel[7, 26] highlighted a few important points relating to the examination of abnormal nails. If these tests are performed, they provide a more accurate examination. Note the following:

  • Always examine all 10 fingernails and all 10 toenails (and any additional digits if they exist). For the most part, fingernails provide more subtle information than toenails because trauma is more likely to change or hide certain clinical manifestations in toenails and because they grow more slowly.
  • Study the nails with the fingers completely relaxed and not pressed against any surface. Failure to do so may affect the nail hemodynamics and change the appearance of the nail.
  • Blanch the fingertip to see if the pigmented abnormality is grossly altered. This test may aid in differentiating the discoloration of the vascular bed of the nail from the discoloration of the nail plate.
  • Illumination of the nail can be achieved with a penlight placed against the finger pulp shining up through the nail. If the discoloration is in the matrix or soft tissue, its exact position can be more easily identified. If upon illumination, the discoloration disappears, it is more likely to be in the vascular bed.
  • Try scraping the surface of the nail plate, or try cleansing locally or cleansing with a solvent (eg, acetone). If in doing so, the discoloration goes away, the cause of the nail alteration is most likely a topical agent. If, however, as a result, the substance used is impregnated further into the nail or subungually, other studies (eg, nail composition studies; potassium hydroxide preparations; biopsy with light microscope, electron microscope, or special staining) may be indicated.
  • Nail changes associated with systemic disease (as opposed to trauma) often occur in the matrix so that the leading edge of the abnormality (pigmentation) is usually shaped like the distal portion of the matrix. To estimate the time at which the initial insult occurred, one can measure the distance from the proximal nail fold (cuticle) to the leading edge of the pigmentation change. The rate of nail growth is about 0.1-0.15 mm/d.[7]
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Causes

Several disease states that cause hypoalbuminemia may be associated with Muehrcke lines. The appearance of paired, white bands is most likely due to a chronic nutritional deficiency of albumin. Examples include nephrotic syndrome, glomerulonephritis, liver disease, and malnutrition. Even though the white bands are most often seen in patients with nephrotic syndrome (of which many causes exist), they are not specific for any one disease state.[1] Additionally, Muehrcke lines of the fingernails have been reported after trauma[27] and chemotherapy.[2, 28]

See Pathophysiology.

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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, University of Medicine and Dentistry of New Jersey-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)

Channing R Barnett, MD  Staff Physician, Department of Dermatology, University of Medicine and Dentistry of New Jersey

Channing R Barnett, MD is a member of the following medical societies: Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

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 Physicians, American Dermatological Association, American Medical Association, Association of Military Surgeons of the US, International Society for Dermatologic Surgery, Noah Worcester Dermatological Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

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.

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.

Joel M Gelfand, MD, MSCE  Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

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.

References

  1. Muehrcke RC. The finger-nails in chronic hypoalbuminaemia; a new physical sign. Br Med J. Jun 9 1956;1(4979):1327-8. [Medline].

  2. Schwartz RA, Vickerman CE. Muehrcke's lines of the fingernails. Arch Intern Med. Feb 1979;139(2):242. [Medline].

  3. Brownson WC. An unusual condition of the nails in pellagra. South Med J. 1915;8:672-5.

  4. Shahani RT, Blackburn EK. Nail anomalies in Hodgkin's disease. Br J Dermatol. Nov 1973;89(5):457-8. [Medline].

  5. Hudson JB, Dennis AJ Jr. Transverse white lines in the fingernails after acute and chronic renal failure. Arch Intern Med. Feb 1966;117(2):276-9. [Medline].

  6. Samman PD, Johnston EN. Nail damage associated with handling of paraquat and diquat. Br Med J. Mar 29 1969;1(5647):818-9. [Medline].

  7. Daniel CR, Sams WM, Scher RK. Nails in systemic disease. In: Nails: Therapy, Diagnosis, Surgery. 2nd ed. Amsterdam: Elsevier Health Sciences; 1997:219-50.

  8. Conn RD, Smith RH. Malnutrition, myoedema, and Muehrcke's lines. Arch Intern Med. Dec 1965;116(6):875-8. [Medline].

  9. Nabai H. Nail changes before and after heart transplantation: personal observation by a physician. Cutis. Jan 1998;61(1):31-2. [Medline].

  10. Morris D, Aisner J, Wiernik PH. Horizontal pigmented banding of the nails in association with adriamycin chemotherapy. Cancer Treat Rep. May-Jun 1977;61(3):499-501. [Medline].

  11. Pratt CB, Shanks EC. Letter: Hyperpigmentation of nails from doxorubicin. JAMA. Apr 22 1974;228(4):460. [Medline].

  12. Priestman TJ, James KW. Letter: Adriamycin and longitudinal pigmented banding of fingernails. Lancet. Jun 14 1975;1(7920):1337-8. [Medline].

  13. Shetty MR. Case of pigmented banding of the nail caused by bleomycin. Cancer Treat Rep. May-Jun 1977;61(3):501-2. [Medline].

  14. Yagoda A, Mukherji B, Young C, Etcubanas E, Lamonte C, Smith JR, et al. Bleomycin, an antitumor antibiotic. Clinical experience in 274 patients. Ann Intern Med. Dec 1972;77(6):861-70. [Medline].

  15. Falkson G, Schultz EJ. Skin changes in patients treated with 5-fluorouracil. Br J Dermatol. Jun 1962;74:229-36. [Medline].

  16. Goldman L, Blaney DJ, Cohen W. Onychodystrophy after topical 5-fluorouracil. Arch Dermatol. Nov 1963;88:529-30. [Medline].

  17. Katz ME, Hansen TW. Nail plate-nail bed separation. An unusual side effect of systemic fluorouracil administration. Arch Dermatol. Jul 1979;115(7):860-1. [Medline].

  18. Shelley WB. Onycholysis due to topical 5-fluorouracil. Acta Derm Venereol. 1972;52(4):320-2. [Medline].

  19. Harrison BM, Wood CB. Cyclophosphamide and pigmentation. Br Med J. May 6 1972;2(5809):352. [Medline].

  20. Shah PC, Rao KR, Patel AR. Letter: Cyclophosphamide-induced nail pigmentation. Lancet. Sep 20 1975;2(7934):548-9. [Medline].

  21. deMarinis M, Hendricks A, Stoltzner G. Nail pigmentation with daunorubicin therapy. Ann Intern Med. Oct 1978;89(4):516-7. [Medline].

  22. Victoroff VM. Transverse white lines in the fingernails induced by combination chemotherapy. Arch Dermatol. Sep 1993;129(9):1217-8. [Medline].

  23. Nixon DW. Alterations in nail pigment with cancer chmotherapy. Arch Intern Med. Oct 1976;136(10):1117-8. [Medline].

  24. James WD, Odom RB. Chemotherapy-induced transverse white lines in the fingernails. Arch Dermatol. Apr 1983;119(4):334-5. [Medline].

  25. Modesto dos Santos V, Sugai TA, Cezar BF, Vasconcellos de Rezende AC. Transverse leukonychia: a case report. West Afr J Med. Apr-Jun 2005;24(2):181-2. [Medline].

  26. Daniel CR 3rd, Osment LS. Nail pigmentation abnormalities. Their importance and proper examination. Cutis. Jun 1980;25(6):595-607. [Medline].

  27. Feldman SR, Gammon WR. Unilateral Muehrcke's lines following trauma. Arch Dermatol. Jan 1989;125(1):133-4. [Medline].

  28. Monteagudo B, Cabanillas M, Suarez-Amor O, Martinez-Calvo L, Grana-Suarez B. [Muehrcke's lines on nails after docetaxel/cisplatin/fluorouracil]. Gastroenterol Hepatol. May 2009;32(5):381-2. [Medline].

  29. Assadi F. Leukonychia associated with increased blood strontium level. Clin Pediatr (Phila). Jul-Aug 2005;44(6):531-3. [Medline].

  30. Dasanu CA, Wiernik PH, Vaillant J, Alexandrescu DT. A complex pattern of melanonychia and onycholysis after treatment with pemetrexed for lung cancer. Skinmed. Mar-Apr 2007;6(2):95-6. [Medline].

  31. Pucevich B, Spencer L, English JC 3rd. Unilateral trachyonychia in a patient with reflex sympathetic dystrophy. J Am Acad Dermatol. Feb 2008;58(2):320-2. [Medline].

  32. Salem A, Al Mokadem S, Attwa E, Abd El Raoof S, Ebrahim HM, Faheem KT. Nail changes in chronic renal failure patients under haemodialysis. J Eur Acad Dermatol Venereol. Nov 2008;22(11):1326-31. [Medline].

  33. Morin G, Desenclos C, Jeanpetit C, Lévy N, Deramond H, Mathieu M. Additional familial case of subtotal leukonychia and sebaceous cysts (Bauer syndrome): belong the nervous tumours to the phenotype?. Eur J Med Genet. Sep-Oct 2008;51(5):436-43. [Medline].

 
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White, transverse, horizontal lines are observed on 4 fingers of a 49-year-old man with adenocarcinoma in his rectosigmoid and adenoma in his sigmoid found in May 2002; he was treated with preoperative radiation and 4 continuous infusions of 5-fluorouracil at the same time.
Close-up view.
White transverse bands are seen on all 10 fingers.
Horizontal white bands are seen on all 10 fingernails.
Close-up view of 4 fingers. White horizontal bands are evident.
Close-up view. White horizontal bands are evident.
 
 
 
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