Hair and nail diseases are congenital or acquired. They may be seen in isolation and independent of each other or associated with skin or systemic disease (e.g. lichen planus of the skin, nails and scarring alopecia). A systematic approach to nail and hair diseases will help identify the cause and aid treatment (Table 25.1).

Nail Diseases

Different presentations, causes and examples of nail diseases are summarised in Table 25.2. Trauma is by far the most common cause of a black or red subungual lesion, but subungual melanoma should be considered in subungual hyperpigmentation. A diagnostic clue is the (often variable) pigmentation of the posterior nail fold (Hutchinson’s sign). A longitudinal nail biopsy will confirm the diagnosis. The whole lesion should be surgically excised with adequate surgical margins. The patient should be followed up regularly for monitoring of recurrence or metastatic disease.

Management

Fungal nail infections require 3–4 months of oral anti-fungal treatment with terbinafine or itraconazole.
Specific treatment of nail changes due to skin or systemic diseases are difficult. Systemic treatment given for the underlying skin disease may improve the nail changes (e.g. methotrexate or biological treatments for psoriasis).
General practical management advice includes keeping nails cut short and moisturised to reduce trauma and breakage of nails. In onycholysis, nail lacquer may improve the cosmetic appearance.

Hair

The human skin has three types of hair. Fine, soft, fair lanugo hair covers most of the fetus’s skin in utero and is shed prior to a full-term birth. Fine vellous hair develops on most of the skin after birth, except for the palms and soles of feet. Coarse, darker terminal hairs occur on the scalp. During puberty, terminal hairs also develop in the axillae, pubic area and beard area in men.

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