eMedicine Specialties > Dermatology > Nails

Muehrcke Lines of the Fingernails: 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): Channing R Barnett, MD, Staff Physician, Department of Dermatology, University of Medicine and Dentistry of New Jersey
Contributor Information and Disclosures

Updated: Nov 15, 2009

Differential Diagnoses

Angiokeratoma Corporis Diffusum (Fabry Syndrome)
Onycholysis
Paronychia
Psoriasis, Nails

Other Problems to Be Considered

Leukonychia
Beau lines
Mees lines
Erythematous crescent
Terry nails
Half-and-half fingernail
Splinter hemorrhages
Leukonychia associated with increased blood strontium level28
Melanonychia with onycholysis29
Reflex Sympathetic Dystrophy: This may be associated with changes including unilateral leukonychia, Beau lines, nailfold swelling, nail clubbing, and unilateral atypical trachyonychia.30

Nails of 100 patients with chronic renal failure under regular hemodialysis were compared with 100 healthy control subjects of matched age and sex.31 . Of these patients, 76% had nail findings, with half and half nails the most common at 20%, followed by — in descending manner — absent lunula, onycholysis, brittle nail, Beau lines, clubbing, longitudinal ridging, onychomycosis, subungual hyperkeratosis, koilonychias, total leukonychia, splinter hemorrhage, pitting, and pincer nail deformity.

 Familial leukonychia may rarely be associated with sebaceous cysts, apparently an autosomal dominant genetic disorder.32

Workup

Laboratory Studies

  • Obtain appropriate laboratory tests as indicated by the history features and the physical examination findings.
  • The most important test is probably serum albumin measurements. Total serum protein levels, serum chemistry enzyme levels, a urine analysis, and a CBC count are also useful tests. In patients being treated for cancer, obtaining the blood levels of certain chemotherapeutic agents is probably important.

Procedures

  • Certain studies, including nail composition studies; potassium hydroxide preparations; or biopsy with light microscope, electron microscope, or special staining, may be indicated.

Histologic Findings

According to Nabai, histopathologic sections of the nail plates show compact orthokeratotic keratinous material in combination with areas suggesting some delay in keratinization. No definite evidence of parakeratotic change is present, and no evidence of distortion or thinning of the nail plates exists.9 James and Odom24 additionally suggested that the injury may lead to the development of parakeratotic or dyskeratotic foci within the nail matrix and retained in the nail plate; however, they were unable to show such histologic changes in their patient.

More on Muehrcke Lines of the Fingernails

Overview: Muehrcke Lines of the Fingernails
Differential Diagnoses & Workup: Muehrcke Lines of the Fingernails
Treatment & Medication: Muehrcke Lines of the Fingernails
Follow-up: Muehrcke Lines of the Fingernails
Multimedia: Muehrcke Lines of the Fingernails
References
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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. Assadi F. Leukonychia associated with increased blood strontium level. Clin Pediatr (Phila). Jul-Aug 2005;44(6):531-3. [Medline].

  29. 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].

  30. 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].

  31. 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].

  32. 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].

  33. Alam M, Scher RK, Bickers DR. Muehrcke's lines in a heart transplant recipient. J Am Acad Dermatol. Feb 2001;44(2):316-7. [Medline].

  34. Aldrich CJ. Leuconychia striata arsenicalis transversus. Am J Med Sci. 1904;127:702-9.

  35. Kennedy BJ, Smith LR, Goltz RW. Skin changes secondary to hydroxyurea therapy. Arch Dermatol. Feb 1975;111(2):183-7. [Medline].

  36. Lindsay PG. The half-and-half nail. Arch Intern Med. Jun 1967;119(6):583-7. [Medline].

  37. Muehrcke RC, Kark RM, Pirani CL. Technique of percutaneous renal biopsy in the prone position. J Urol. Sep 1955;74(3):267-77. [Medline].

  38. Pardo-Castello V, Pardo OA. Diseases of the Nails. 1960;135-138.

  39. Urbach E. White cross striae of the finger nails following cardiac infarction. Arch Dermatol Syphilol. 1945;52:106-7.

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Further Reading

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Keywords

Muehrcke lines of the fingernails, Muehrcke lines, Muehrcke's lines, white lines, hypoalbuminemia, serum albumin deficiency, serum albumin level, chemotherapy-induced nail changes, pigmented banding on the nails

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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)

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.

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

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 None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

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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