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Muehrcke Lines of the Fingernails Differential Diagnoses

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
Updated: Jun 22, 2016

Diagnostic Considerations

Also consider the following:

  • Leukonychia
  • Beau lines
  • Mees lines
  • Erythematous crescent
  • Terry nails
  • Half-and-half fingernail
  • Splinter hemorrhages
  • Leukonychia associated with increased blood strontium level [32]
  • Melanonychia with onycholysis [33]
  • Onychopapilloma: This benign nail bed neoplasm may be associated with leukonychia. [34]
  • Reflex Sympathetic Dystrophy: This may be associated with changes including unilateral leukonychia, Beau lines, nailfold swelling, nail clubbing, and unilateral atypical trachyonychia. [35]

Nails of 100 patients with chronic renal failure under regular hemodialysis were compared with 100 healthy control subjects of matched age and sex.[36] 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.

Various types of leukonychia may be considered, including leukonychia punctata, leukonychia striata, leukonychia partialis, and leukonychia totalis.[37, 38, 39] “ True” leukonychia involves the nail plate and “apparent” leukonychia derives from the nail bed.[40] Familial leukonychia may rarely be associated with sebaceous cysts, apparently an autosomal dominant genetic disorder.[41] True acquired leukonychia may be associated with trauma, chemotherapeutic agents, hypocalcemia, zinc deficiency, heavy metal poisoning, local infection, and systemic diseases.[42] Selenium deficiency has also been suggested as a possible etiology.[40]

Loss-of-function mutations in calpastatin may produce a syndrome of generalized peeling skin, leukonychia, acral punctate keratoses, cheilitis, and knuckle pads.[43]

Differential Diagnoses

Contributor Information and Disclosures

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.


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

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Warren R Heymann, MD Head, Division of Dermatology, Professor, Department of Internal Medicine, Rutgers New Jersey Medical School

Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of 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. Muehrcke RC. The finger-nails in chronic hypoalbuminaemia; a new physical sign. Br Med J. 1956 Jun 9. 1(4979):1327-8. [Medline].

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

  3. Lipner SR, Scher RK. Evaluation of nail lines: Color and shape hold clues. Cleve Clin J Med. 2016 May. 83 (5):385-91. [Medline].

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

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

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

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

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

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

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

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

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

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

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

  15. 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. 1972 Dec. 77(6):861-70. [Medline].

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

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

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

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

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

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

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

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

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

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

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

  27. 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):e181-9. [Medline].

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

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

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

  31. Chávez-López MA, Arce-Martínez FJ, Tello-Esparza A. Muehrcke lines associated to active rheumatoid arthritis. J Clin Rheumatol. 2013 Jan. 19(1):30-1. [Medline].

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

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

  34. Tosti A, Schneider SL, Ramirez-Quizon MN, Zaiac M, Miteva M. Clinical, dermoscopic, and pathologic features of onychopapilloma: A review of 47 cases. J Am Acad Dermatol. 2016 Mar. 74 (3):521-6. [Medline].

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

  36. 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. 2008 Nov. 22(11):1326-31. [Medline].

  37. Arsiwala SZ. Idiopathic acquired persistent true partial to total leukonychia. Indian J Dermatol Venereol Leprol. 2012 Jan. 78(1):107-8. [Medline].

  38. Farooq M, Kurban M, Abbas O, et al. A novel mutation in the PLCD1 gene, which leads to an aberrant splicing event, underlies autosomal recessive leukonychia. Br J Dermatol. 2012 Mar 28. [Medline].

  39. Clayton N, Atkar R, Verdolini R. Ten bright-white fingernails in two young healthy patients. Congenital total (patient 1) and subtotal (patient 2) leuconychia (white nails syndrome, or milky nails). Clin Exp Dermatol. 2012 Mar. 37(2):201-2. [Medline].

  40. Hasunuma N, Umebayashi Y, Manabe M. True leukonychia in Crohn disease induced by selenium deficiency. JAMA Dermatol. 2014 Jul. 150(7):779-80. [Medline].

  41. 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. 2008 Sep-Oct. 51(5):436-43. [Medline].

  42. Kim SW, Kim MS, Han TY, Lee JH, Son SJ. Idiopathic acquired true leukonychia totalis and partialis. Ann Dermatol. 2014 Apr. 26(2):262-3. [Medline]. [Full Text].

  43. Lin Z, Zhao J, Nitoiu D, Scott CA, Plagnol V, Smith FJ, et al. Loss-of-function mutations in CAST cause peeling skin, leukonychia, acral punctate keratoses, cheilitis, and knuckle pads. Am J Hum Genet. 2015 Mar 5. 96 (3):440-7. [Medline].

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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