Terry’s Nails

Description

Terry’s nails are a type of apparent leukonychia, characterized by ground glass opacification of almost the entire nail, with a narrow band of normal, pink nail bed at the distal border, and often with obliteration of the lunula.

The narrow pink/ brown segment (0.5 – 3 mm) of the distal border before the lunula indicates normal nail bed tissue. Opacity varies in degree and distribution: the most severe change is a proximal white nail with a dark band distally as shown below.

History

1954 Initially described by Richard Terry in patients with hepatic cirrhosis (sign demonstrated in 82 of 100 cirrhotic patients) p < 0.01. The narrow pink/ brown segment (0.5 – 3 mm) of the distal border before the lunula indicated normal nail bed tissue and that this is the prominent feature. Terry investigated “Opacity of the nail bed causing apparent whiteness of the finger-nails, and its occurrence in cirrhosis of the liver and some other conditions.” The whitened appearance of the nail due to underlining defects of the nail bed was termed ‘apparent leuconychia’.

Fully developed white nails exhibit a ground-glass- like opacity of almost the entire nail bed. It extends from the base of the nail, where the lunula is indistinguishable, to within one or two millimetres of the distal border of the nail bed, leaving a distal zone of normal pink. The condition is bilaterally symmetrical, with a tendency to be more marked in the thumb and forefinger.

Terry 1954

The pathophysiology remains underdetermined but currently thought to be due to changes in nail bed vascularity secondary to overgrowth of connective tissue. Nail bed tissue biopsy confirm microvascular involvement showing telangiectasias in the upper dermis of the distal band.

These nails are common in cirrhosis of the liver and may fairly be added to the list of non-specific physical signs thereof. Their diagnostic value in cirrhosis is limited, since they occur in other conditions, but they are occasionally most helpful in suggesting or corroborating the diagnosis.

Terry 1954

This sign is also found in systemic diseases such as chronic congestive heart failure (p <0.01), adult onset diabetes mellitus (p< 0.001) but also pulmonary tuberculosis, rheumatoid arthritis, convalescent viral hepatitis, disseminated sclerosis, renal failure and metastatic cancer. Terry’s nail is part of normal ageing and the above systemic diseases “age” the nails quicker than normal.

The differential diagnosis for Terry’s nails includes half-and-half nails (Lindsay’s nails), Muehrcke’s nails, and true leukonychia totalis/partialis 

Associated Persons

• Richard Barratt Terry (1914 – 1960)

Alternative names

• Terry nails

References

• Burrows MT. The significance of the lunula of the nail. The Anatomical Record 1917; 12(1): 161-166
• Howard et al. Leukonychia in three generations. Journal of cutaneous diseases 1917; 35: 559
• Pernet G. Case of Multiple Leuconychia Striata, associated with Leuconychia Totalis of One Thumb Nail. Proc R Soc Med. 1919; 12(Dermatol Sect): 28‐29.
• Weis. Leukonychia. Journal of cutaneous diseases 1918; 36: 594-95.
• Kleeberg J. Flat finger-nails in cirrhosis of the liver. Lancet. 1951;2(6676):248‐249.
• Terry R. White nails in hepatic cirrhosis. Lancet. 1954; 266(6815): 757‐759.
• Morey DA, Burke JO. Distinctive nail changes in advanced hepatic cirrhosis. Gastroenterology 1955; 29: 258-61.
• Stewart WK, Raffle EJ. Brown nail-bed arcs and chronic renal disease. Br Med J. 1972; 1(5803): 784‐786.
• Holzberg M, Walker HK. Terry’s nails: revised definition and new correlations. Lancet. 1984;1(8382):896‐899
• Nia AM, Ederer S, Dahlem KM, Gassanov N, Er F. Terry’s nails: a window to systemic diseases. Am J Med. 2011;124(7):602‐604.
• Pitukweerakul S, Pilla S. Terry’s Nails and Lindsay’s Nails: Two Nail Abnormalities in Chronic Systemic Diseases. J Gen Intern Med. 2016;31(8):970.
• Witkowska AB, Jasterzbski TJ, Schwartz RA. Terry’s Nails: A Sign of Systemic Disease. Indian J Dermatol. 2017; 62(3): 309‐311.
• Flores L, Moreira H, Pinto MJ, Andrade C, Friões F. Terry’s nails, tracking an underneath disease. Postgrad Med J. 2019;95(1125):405.
• Meegada S, Verma R. Terry’s nails. Clin Case Rep. 2020; 8(2): 404‐405.