History
Brittle nail syndrome classically develops gradually. Patients may disclose that their nail abnormalities were initially mild and worsened over time, causing additional pain or discomfort. The brittle nail findings may be associated with the onset of systemic disease, in certain cases.
Physical Examination
Classic physical examination findings for onychorrhexis include shallow, parallel longitudinal furrows of the nail, often leading to distal longitudinal breakage along a furrow. [4] The furrows may even look as though they have been scratched by sandpaper. [5] The physical examination for onychoschizia likely will reveal transverse lamellar splitting of the distal free edge portion of the nail plate. [1]
The following grading system has been recommended to assess the severity of onychoschizia and onychorrhexis as components of brittle nail syndrome. [1]
Onychoschizia
Table 1. Proposed Score for Lamellar Splitting (Open Table in a new window)
Lamellar splitting defined as onychoschizia |
0 = None, clear of clinical signs of lamellar nail splitting |
1 = Mild, distal furrows, parallel to the back surface, not involving the entire free edge of the nail plate |
2 = Moderate, distal parallel furrows of the superficial nail plate involving the complete free edge of the nail plate |
3 = Severe, distal lamellar splitting of the complete free edge of the nail plate, lamellar splits covering at least one third of the nail plate |
Table 2. Proposed Score for Transverse Splitting (Open Table in a new window)
Horizontal nail splitting from the free edge of the nail plate |
0 = None, clear of clinical signs from the free edge of the nail plate |
1 = Mild, one superficial horizontal split of the distal nail plate |
2 = Moderate, 2-3 horizontal splits of the distal nail plate |
3 = Severe, multiple horizontal splits leading to loosening of at least one third of the distal nail plate |
Onychorrhexis
Table 3. Proposed Score for Ridging (Open Table in a new window)
Assessment of ridges and longitudinal grooves |
0 = None, clear of any signs of ridging and longitudinal grooves |
1 = Mild, few plane ridges and longitudinal grooves |
2 = Moderate, few deep ridges and longitudinal grooves |
3 = Severe, more than 70% of the nail plate showing deep ridges and corresponding grooves |
Table 4. Proposed Score for Longitudinal Splitting (Open Table in a new window)
Longitudinal splitting as derived from the nail matrix and defined as onychorrhexis |
0 = None, clear of clinical signs of longitudinal nail splitting |
1 = Mild, one single, superficial longitudinal split of the nail plate |
2 = Moderate, at least one deep longitudinal split of the entire nail plate |
3 = Severe, multiple, superficial and deep longitudinal splits of the nail plate |
Complications
This syndrome may cause significant pain and discomfort for patients, as well as increased risk of nail breakage owing to the nail plate fragility. It may also lead to functional impairment in severe cases.
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Brittle nail syndrome: Significant longitudinal ridging of the L1 and R1 fingernails in an otherwise healthy 77-year-old woman, consistent with onychorrhexis stage 3 ridging per grading criteria proposed by van de Kerkhof and colleagues. Courtesy of Amanda E Zubek, MD, PhD, FAAD.
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Brittle nail syndrome: Horizontal splitting of the free margin of the nail consistent with lamellar onychoschizia. Courtesy of Springer Healthcare (Dermatology and Therapy, 20 Nov 2019).
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Brittle nail syndrome: Moderate-to-significant longitudinal ridging of the R2-R5 fingernails in an otherwise healthy 77-year-old woman. Courtesy of Amanda E Zubek, MD, PhD, FAAD.
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Brittle nail syndrome: A 75-year-old woman with a history of hypothyroidism with moderate-to-severe longitudinal ridging of the L2-L4 fingernails consistent with onychorrhexis. Courtesy of Amanda E Zubek, MD, PhD, FAAD.
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Brittle nail syndrome: A 75-year-old woman with a history of hypothyroidism with moderate-to-severe longitudinal ridging of the R2-R4 fingernails, consistent with onychorrhexis. Courtesy of Amanda E Zubek, MD, PhD, FAAD.
Tables
Lamellar splitting defined as onychoschizia |
0 = None, clear of clinical signs of lamellar nail splitting |
1 = Mild, distal furrows, parallel to the back surface, not involving the entire free edge of the nail plate |
2 = Moderate, distal parallel furrows of the superficial nail plate involving the complete free edge of the nail plate |
3 = Severe, distal lamellar splitting of the complete free edge of the nail plate, lamellar splits covering at least one third of the nail plate |
Horizontal nail splitting from the free edge of the nail plate |
0 = None, clear of clinical signs from the free edge of the nail plate |
1 = Mild, one superficial horizontal split of the distal nail plate |
2 = Moderate, 2-3 horizontal splits of the distal nail plate |
3 = Severe, multiple horizontal splits leading to loosening of at least one third of the distal nail plate |
Assessment of ridges and longitudinal grooves |
0 = None, clear of any signs of ridging and longitudinal grooves |
1 = Mild, few plane ridges and longitudinal grooves |
2 = Moderate, few deep ridges and longitudinal grooves |
3 = Severe, more than 70% of the nail plate showing deep ridges and corresponding grooves |
Longitudinal splitting as derived from the nail matrix and defined as onychorrhexis |
0 = None, clear of clinical signs of longitudinal nail splitting |
1 = Mild, one single, superficial longitudinal split of the nail plate |
2 = Moderate, at least one deep longitudinal split of the entire nail plate |
3 = Severe, multiple, superficial and deep longitudinal splits of the nail plate |
