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.^[10]James and Odom^[26]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.

Treatment & Management

Muehrcke RC. The finger-nails in chronic hypoalbuminaemia; a new physical sign. Br Med J. 1956 Jun 9. 1(4979):1327-8. [QxMD MEDLINE Link].
Schwartz RA, Vickerman CE. Muehrcke's lines of the fingernails. Arch Intern Med. 1979 Feb. 139(2):242. [QxMD MEDLINE Link].
Lipner SR, Scher RK. Evaluation of nail lines: Color and shape hold clues. Cleve Clin J Med. 2016 May. 83 (5):385-91. [QxMD MEDLINE Link].
Brownson WC. An unusual condition of the nails in pellagra. South Med J. 1915. 8:672-5.
Shahani RT, Blackburn EK. Nail anomalies in Hodgkin's disease. Br J Dermatol. 1973 Nov. 89(5):457-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Samman PD, Johnston EN. Nail damage associated with handling of paraquat and diquat. Br Med J. 1969 Mar 29. 1(5647):818-9. [QxMD MEDLINE Link].
Daniel CR, Sams WM, Scher RK. Nails in systemic disease. Nails: Therapy, Diagnosis, Surgery. 2nd ed. Amsterdam: Elsevier Health Sciences; 1997. 219-50.
Conn RD, Smith RH. Malnutrition, myoedema, and Muehrcke's lines. Arch Intern Med. 1965 Dec. 116(6):875-8. [QxMD MEDLINE Link].
Nabai H. Nail changes before and after heart transplantation: personal observation by a physician. Cutis. 1998 Jan. 61(1):31-2. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Pratt CB, Shanks EC. Letter: Hyperpigmentation of nails from doxorubicin. JAMA. 1974 Apr 22. 228(4):460. [QxMD MEDLINE Link].
Priestman TJ, James KW. Letter: Adriamycin and longitudinal pigmented banding of fingernails. Lancet. 1975 Jun 14. 1(7920):1337-8. [QxMD MEDLINE Link].
Shetty MR. Case of pigmented banding of the nail caused by bleomycin. Cancer Treat Rep. 1977 May-Jun. 61(3):501-2. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Falkson G, Schultz EJ. Skin changes in patients treated with 5-fluorouracil. Br J Dermatol. 1962 Jun. 74:229-36. [QxMD MEDLINE Link].
Goldman L, Blaney DJ, Cohen W. Onychodystrophy after topical 5-fluorouracil. Arch Dermatol. 1963 Nov. 88:529-30. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Shelley WB. Onycholysis due to topical 5-fluorouracil. Acta Derm Venereol. 1972. 52(4):320-2. [QxMD MEDLINE Link].
Harrison BM, Wood CB. Cyclophosphamide and pigmentation. Br Med J. 1972 May 6. 2(5809):352. [QxMD MEDLINE Link].
Shah PC, Rao KR, Patel AR. Letter: Cyclophosphamide-induced nail pigmentation. Lancet. 1975 Sep 20. 2(7934):548-9. [QxMD MEDLINE Link].
deMarinis M, Hendricks A, Stoltzner G. Nail pigmentation with daunorubicin therapy. Ann Intern Med. 1978 Oct. 89(4):516-7. [QxMD MEDLINE Link].
Victoroff VM. Transverse white lines in the fingernails induced by combination chemotherapy. Arch Dermatol. 1993 Sep. 129(9):1217-8. [QxMD MEDLINE Link].
di Meo N, Longone M, Retrosi C, Zalaudek I. Drug-induced longitudinal melanonychia and transverse muehrcke's lines. J Eur Acad Dermatol Venereol. 2018 May 6. [QxMD MEDLINE Link].
Nixon DW. Alterations in nail pigment with cancer chmotherapy. Arch Intern Med. 1976 Oct. 136(10):1117-8. [QxMD MEDLINE Link].
James WD, Odom RB. Chemotherapy-induced transverse white lines in the fingernails. Arch Dermatol. 1983 Apr. 119(4):334-5. [QxMD MEDLINE Link].
Feldman SR, Gammon WR. Unilateral Muehrcke's lines following trauma. Arch Dermatol. 1989 Jan. 125(1):133-4. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Mohaghegh F, Danesh F. Muehrcke's lines in a psoriatic patient: A possible association with acitretin therapy. Clin Case Rep. 2019 Nov. 7 (11):2212-2214. [QxMD MEDLINE Link].
Saraswat N, Sood A, Verma R, Kumar D, Kumar S. Nail Changes Induced by Chemotherapeutic Agents. Indian J Dermatol. 2020 May-Jun. 65 (3):193-198. [QxMD MEDLINE Link].
Williams V, Jayashree M. Muehrcke Lines in an Infant. J Pediatr. 2017 Jun 5. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Kozaru T, Fukumoto T, Shirai T, Takasawa N, Kameoka JI, Oka M. Muehrcke lines on fingers and toenails. Eur J Dermatol. 2019 Feb 1. 29 (1):87-88. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Daniel CR 3rd, Osment LS. Nail pigmentation abnormalities. Their importance and proper examination. Cutis. 1980 Jun. 25(6):595-607. [QxMD MEDLINE Link].
Assadi F. Leukonychia associated with increased blood strontium level. Clin Pediatr (Phila). 2005 Jul-Aug. 44(6):531-3. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Arsiwala SZ. Idiopathic acquired persistent true partial to total leukonychia. Indian J Dermatol Venereol Leprol. 2012 Jan. 78(1):107-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Hasunuma N, Umebayashi Y, Manabe M. True leukonychia in Crohn disease induced by selenium deficiency. JAMA Dermatol. 2014 Jul. 150(7):779-80. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].

Media Gallery

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.

of 6

Author

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

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, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Former 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: Alpha Omega Alpha, American Academy of Dermatology, Association of Military Dermatologists, Phi Beta Kappa, Texas Dermatological Society

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.

Sections Muehrcke Lines of the Fingernails
Overview
Presentation
DDx
Workup
Treatment
Media Gallery
References

Muehrcke Lines of the Fingernails Workup

Laboratory Studies

Procedures

Histologic Findings

References

Tables

Contributor Information and Disclosures

What would you like to print?