Yellow nail syndrome

A 68-year-old woman presents with a 2-year history of changing color in her nails. The proximal portion of the nails has become lighter in color and the distal portion has turned reddish-brown. The nails have remained asymptomatic. The patient is in good health, except for mild hypertension, for which she takes an ACE inhibitor. She has no history of liver or kidney disease.

On examination, all fingernails have a proximal white discoloration with a distal band of red-brown color (figure). The lunula is absent. Aside from minimal periungual erythema in some fingers, no other pathologic changes are present.

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Differential diagnosis

Consider conditions that produce nail discoloration. Drug-induced nail discoloration from medications, such as minocycline and cancer chemotherapy, can result in a color change, but this is usually diffuse hyperpigmentation rather than a mixture of hypopigmentation and red-brown discoloration.

Nail polishes or other nail care products can stain the nail a brownish color, which might be consistent with what is happening at the distal portion of the nail. This diagnosis would not explain the light color over the remainder of the nail.

Yellow nail syndrome is a condition associated with pulmonary disease, where the nails acquire a lusterless, yellowish color. The two-tone hue of these nails makes this diagnosis less likely.

Raynaud's phenomenon, a disorder of blood circulation in the fingers, can cause color dilution of the nails and the rest of the distal digit. However, the nails return to a normal color after the vasospasm has subsided.

Half and half nails is the correct diagnosis. The name is somewhat misleading, since up to 90% of the nail is white and the rest is red-brown. The lunula is typically not visible. In most cases, this is an idiopathic condition in otherwise normal people. There have been a few reports of the association of this finding and active renal or hepatic disease. There is no treatment for this condition, which is permanent. The only possible therapy is cover-up nail polish.

Diagnostic pearl

In half and half nails, the proximal portion of the nails turns white and the distal portion is red-brown.

Dr. Levine is professor of medicine (dermatology), University of Arizona Health Sciences Center, Tucson.

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