Online Health Chat with Thomas Knackstedt, MD

Wednesday, April 5, 2017


If you want some clues about your overall health, look down at your nails. Your nails are a good reflection of your health. Many things can occur in the nails that can signify systemic or skin problems, including inflammation, infections or cancers.

The Department of Dermatology at Cleveland Clinic offers a full array of subspecialized care for adult and pediatric patients. Our physicians provide expert diagnosis and treatment of all disorders of the skin, hair and nails, whether primary or related to an underlying systemic illness, including industrial-related conditions.

The department also offers a full range of procedures in the area of dermatologic surgery, including laser surgery, chemical peels, soft tissue augmentation, BOTOX® injections, hair transplant, liposuction and Mohs micrographic surgery, which provides the highest cure rate for high-risk melanoma skin cancers while sparing the maximum amount of normal skin.

To see a full listing of our dermatologic services, specialists and locations, visit

About the Speaker

Thomas Knackstedt, MD, is an associate staff physician in the Department of Dermatology at Cleveland Clinic and specializes in Mohs surgery, skin cancer and nail health. He is board-certified in dermatology and fellowship-trained in dermatologic oncology and Mohs micrographic surgery. He has authored numerous publications on skin cancer and nail disease.

Let’s Chat About Nails and Your Health

Visible Concerns

Health_Nut: My nails often have white specs on them. They kind of look like they were scrapped on something but they weren't. What could this mean?

Thomas_Knackstedt,_MD: White specks on the nails are not uncommon. In most instances, they correlate with times of minor injury to the root of the nail. Such injuries could include nail biting, habitual nail rubbing or any manipulation (including trimming or pushing back) of the cuticle. These white discolorations usually grow out as the nail grows out.

Doverstblues: Why should I be concerned about the discoloration of my nails?

Thomas_Knackstedt,_MD: There are many reasons for nails to be discolored. Most importantly, a brown line in the nail may represent a pigmented nail lesion such as a freckle, mole or, rarely, a melanoma. Especially in light skin individuals, such lesions should be evaluated by a dermatologist. Similarly, red lines may be caused by many benign, noncancerous growths within the root of the nail. However, rarely, red lines in the nail may be due to a wart or a squamous cell cancer of the nail, and widening, painful red lines in a single nail should be evaluated by a dermatologist. Most yellow discoloration of the nails (especially toenails) is due to fungal infections, which are very common. These infections, called onychomycosis, do not always required treatment. If treatment is desired, many primary care physicians are able to treat it with topical or oral therapy.

Lott: Please describe "clubbing."

Thomas_Knackstedt,_MD: Clubbing is most easily recognized based on an image, as the appearance is relatively unique. Described in words, clubbing represents a change in the normal angle between the nail bed and the cuticle. This occurs together with increased convexity (curvature) of the nail plate. Ultimately, the above remains a very vague description, and clubbing remains a very uncommon finding of the nails. A concern for clubbing can certainly be evaluated by a primary care physician.

loveitaly: I like to do pedicures every three to four months because I know that doing them too often is not good for nails. Lately, I have noticed that when I removed the color at home, some of the nails, especially on the big toes, are a little flaky and whitish in parts, and it takes several weeks for this to go away. Is that a fungus? My sister and a friend have had the same experience at different nail salons. Thanks for your time.

Thomas_Knackstedt,_MD: Thank you for your question. These findings may represent a fungal infection, but are somewhat nonspecific, so there may be other reasons as well. Trauma to the cuticle (cutting, pushing back, trimming) may cause the nail to grow out irregularly and with the white color. Irritation from nail polish remover may have similar effects. Certainly nail fungus is a very common diagnosis, but it is not always the culprit.

loveitaly: About five year ago, I noticed my left thumb nail wasn't growing from the side to about 1/8 inch inside toward the midline of nail. I then noticed my thumb nail has a curvature that probably occurred because I hit my nail with something, and the nerve of that area got affected so that part of the nail won't grow. I don't remember having hit my finger or anything. It has been like that all this time, and I have to file it very close to the skin because it grows unevenly. Could it have been that the nerve was affected in the way I described? Thanks.

Thomas_Knackstedt,_MD: Thank you for your question. In general, there is not a close relationship between the health of the nerves in the finger and nail growth. Nail growth is very similar to hair growth in that regard. The trauma that may have caused nerve damage may have also affected the nail unit and caused a scar in the root of the nail, which is resulting in this different nail growth. Certainly, any nail changes that are bothersome to you can be evaluated by a dermatologist experienced in nail disorders.

pops502: One of my toenails next to my big toe had a black spot at its base. My doctor thought it was a blood blister. The toenail next to it has become black for the complete toenail. Should I go back to my doctor?

Thomas_Knackstedt,_MD: Both of these lesions likely represent subungual hematomas (bruises) due to trauma. Generally, as I discussed with other guests, these grow out over time as the nail grows out. This may be a slow process over six to 12 months. Any nail discoloration not growing out appropriately may warrant evaluation by a dermatologist or primary care physician.

Nurturing Nails

Rice78: Thank you for this opportunity. Can you describe a routine that will help with maintaining healthy nails?

Thomas_Knackstedt,_MD: In general, no maintenance is required for the nails apart from clipping them with sharp clippers. Toenails are best squared off, as round edges occasionally predispose to ingrowing of the nails. Most individuals do not require Biotin supplementations, but this is sometimes helpful if the nails are brittle.

Swanson2589: What vitamins are good for my nails?

Thomas_Knackstedt,_MD: Generally speaking, no supplemental vitamins are required for nail health. Biotin and selenium are involved in the production of healthy nails; however, most individuals obtain sufficient levels of these nutrients from their nutrition. In some cases of brittle nails, biotin supplementation may be helpful. Biotin may be purchased without a prescription at the pharmacy or health food store. Dosing is usually biotin 2-3 mg daily for six months. If there is no improvement within this time, biotin is unlikely to be helpful in the future. A consultation with a dermatologist may be beneficial at that time.

Silver905: Do acrylic nails affect the overall health of the nail?

Thomas_Knackstedt,_MD: In most individuals, acrylic nails do not affect the health of the nail. However, some individuals develop a contact allergy to the dyes or glues used in acrylic nails. For most nail care, the most irritating aspect is actually the removal, be it of artificial nails or of nail polish with acetone or acetone-free nail polish removers. Again, in most patients, such irritation is minimal and nail care is well tolerated, but select individuals may find their nails noticeably more brittle, pitted and discolored.

Misty14: What type of nail polish remover is safe to use?

Thomas_Knackstedt,_MD: In general, all commercially available nail polish removers are safe. I usually recommend acetone-free nail polish remover. It is important to know that nail polish removers of any type contain much more harsh chemicals than the nail polish itself. Thus, many of the changes that are sometimes seen related to nail polish problems (brittle nails, dull without shine, pits in the nails) may be due to the nail polish remover rather than the nail polish. Repeated applications of acetone/nail polish remover may dehydrate the nails and can contribute to their brittleness. I recommend the use of toluene-free and formaldehyde-free nail products only. Most major manufacturers (Almay, Clinique, Elizabeth Arden, Revlon, Channel, Zoya) carry these products.

Lines and Ridges

pilatesgirl: What causes longitudinal ridges, and why are they on some fingers and not others, especially on the thumb, pinky and ring finger?

Thomas_Knackstedt,_MD: Many patients on this chat today and daily in the clinic are bothered by ridging of the nails. In most instances, this is a benign condition that is not worrisome. Ridging nails (also called onychorrhexis) is seen most commonly with advancing age, and I frequently compare it to "graying of the hair." The exact cause is not known. Some patients have found biotin 2-3 mg supplementation daily to be helpful. This can be taken for up to six months at which point any improvement in the nails should be visible.

PinkRose17: What are Beau’s lines?

Thomas_Knackstedt,_MD: Beau’s lines are transverse depressions across one or multiple fingernails. They represent periods of decreased nail growth (less thick nail growth). Brittle nails are often a normal result of aging. At other times, they may be due to other reasons including injury to the nail, trauma, stress, medical illness or certain medications. Beau’s lines grow out as the nail grows out.

Carie: I am a 65-year-old female. All my fingernails have vertical ridges, which I've read is common with aging and not a concern. My question is that most of my fingernails are also wavy on the tips, with some curving inward from the side and some curving down toward the fingertip skin. Is this normal aging also?

Thomas_Knackstedt,_MD: Thank you for your message. By your description, your nail findings sound like "spoon nails" or koilonychia. In the majority of cases, this is part of aging and happens without other causes. However, in some individuals, this may be a sign of iron deficiency, and if the symptoms persist or worsen, you may wish to follow up with your primary care physician for basic lab work.

robtoby: Hello. I'm a male and almost 63 years old. I've noticed over the past few years that a few of my nails have what I'd call vertical raised “ridges” in them, also very small, narrow “ovals” along those ridges. Are these just a sign of aging? Thanks.

Thomas_Knackstedt,_MD: This is a recurring question that can be challenging to answer, since there are so many nuances in the examination of nails. It sounds by your description that you mostly have ridges and pitting (narrow ovals). While this may be due to normal maturation and aging of the nail, sometimes such findings are caused by inflammation in the nail by conditions such as lichen planus or psoriasis. Lichen planus and psoriasis are both skin rashes that can involve the nail unit, even in the absence of other skin changes. If this remains bothersome, evaluation by a dermatologist experienced in nail conditions may be valuable.

Jamie9: I have a 10-year-old daughter with some nail issues. The ring fingernail on her left hand feels and looks wrinkled (vertically). She'll get a white spot on her nails here and there. Then, on her big toenails, she has vertical lines, and the nails are cracked at some of the lines. The same is true with one pinky toe. Any idea what causes this? Could it be a nutritional/vitamin/mineral deficiency? Is it something that can be corrected?

Thomas_Knackstedt,_MD: Thank you for your message. It seems that there are multiple questions that I will try to address. 1) Regarding the vertical crack on one finger, this may benefit from further evaluation by a dermatologist experienced in nail disorders. It is difficult to make any assumptions without seeing the lesion. 2) Superficial white spots on the nail are oftentimes due to small periods of injury to the nail, most commonly biting or picking the nail or cuticle. Most often, these discolorations grow out with the nail. 3) I often receive questions regarding nutritional deficiencies from my patients. Interestingly, most nail changes have no relationship to nutrition. Nutritional deficiency is quiet rare and, even when present, most often does not involve the nails. As I discussed with another guest, iron deficiency may cause spoon nails, but this is an uncommon phenomenon. I hope this helps.

clihea2: I am 81 and have severe ridges on my nails, which also make the edges rough, catch on things and tear down into nail bed. Is there anything that can be done to reduce the formation of ridges?

Thomas_Knackstedt,_MD: This is a recurring question that can be challenging to answer since there are so many nuances in the examination of nails. It sounds like you are having ridges and depressions, some of them deep enough to cause splitting. While this may be due to normal maturation and aging of the nail, sometimes such findings are caused by inflammation in the nail by conditions such as lichen planus or psoriasis. The treatment is very much guided by the cause for the ridges. If treatment is desired, in person evaluation by a dermatologist experienced in nail conditions may be valuable.

Disordered Descriptions

AnneRanders: I feel like my nails have become very brittle and break and crack easily. What could be the cause of this?

Thomas_Knackstedt,_MD: The exact explanation for many cases of brittle nails is unknown. There is conflicting evidence that brittle nails are caused by extreme dryness of the nail. It is true that nails are less able to hold onto moisture than skin and thus dry out more easily. Frequent wetting/drying, as well as exposure to extremes of humidity and temperature, will dry out nails. Repeated injury and use of certain nail products (polish removers, in particular) and chemicals may also weaken the nail. Paradoxically, nail hardeners can predispose the nail to breaking more easily. Treatment of brittle nails is frustrating and difficult. The initial approach focuses on removing outside factors (such as frequent washing, wetting/drying or exposure to chemicals) that may cause or exacerbate nail fragility. Re-hydrating measures such as applications of moisturizer are important. Occasionally, the once-a-week use of nail enamel is encouraged to slow water evaporation from the nail plate.

GroKenHaM: My wife and I are in our late 70's and have serious problems with our nails cracking and splitting. My situation is somewhat worse, since the problem affects the feet also. I had one dermatologist call it a "vegetative allergy," since it started with an itch on a finger after contacting some nasty vines. A dermatologist at Cleveland Clinic gave me 30 seconds when I was being biopsied by a physician's assistant and suggested psoriasis. I have no current scaling of any type, although I did have some on my feet a year ago that was treated successfully with a psoriasis cream. Any suggestions for either of us would be appreciated.

Thomas_Knackstedt,_MD: Thank you for your comments. As I mentioned, most changes in the nail that present with cracking and splitting are due to "aging of the nail." Please see my other comments regarding this phenomenon. However, as you correctly identified, psoriasis can affect the nails. This may cause pitting of the nail, redness of the nail bed or lifting of the nails. In such instances, evaluation with a dermatologist experienced in nail disorders may be helpful, as there may be specific treatments for the psoriasis affecting the nails. Importantly, not all patients with nail psoriasis have psoriasis elsewhere. Indeed, some patients only have nail psoriasis and no other rash.

pilatesgirl: Why do some people have stronger nails than others? Is there a genetic component? Does biotin really work to help hair and nails?

Thomas_Knackstedt,_MD: Thank you for your message. This seems to be a common problem. There is certainly a strong genetic component to nail health. Truthfully, our understanding of nail strength is relatively limited, and it has been difficult to pinpoint the exact cause for strong (versus weak nails). Biotin is a safe supplement and can certainly be tried. It has the most scientific evidence in the treatment of brittle nails.

Salamander: Why do nails (especially toenails) thicken as one ages? When does this typically begin?

Thomas_Knackstedt,_MD: There are many causes for the thickening of the nails with age. The two most common causes are nail fungus infection and altered biomechanics due to repeat trauma in a tight shoe, the bone pushing up against the nail or a misalignment of the nail. Both diagnoses can present with yellow discoloration and thickening of the nails. A precise age is difficult to pinpoint, but most of my patients with such changes are 50 to 60 years old and older.

Frightful Fungus

principal11: What are some signs of nail fungus, and how should it be treated?

Thomas_Knackstedt,_MD: Thank you for your question. Most nail fungus presents with yellow discoloration, thickening of the nail plate and, at times, debris under the nail plate itself. Some forms of nail fungus may also present with white, chalky discoloration of the upper parts of the nail plate. It is important to note that fungal infections are the most common diagnosis of the nails, but also the most common MISDIAGNOSIS, since nail changes can look very similar regardless of the underlying cause. For that reason, it is often recommended to confirm the diagnosis of nail fungus with testing first. Once the diagnosis is confirmed, different topical creams and solutions or oral pills can be used. Not all nail fungus requires treatment, and many patients are not bothered by their nail fungus and choose not to treat it.

Hematite: What is the significance of nail fungus on two left fingers (thumb and middle) and the left big toe?

Thomas_Knackstedt,_MD: Thank you for your question. Please see my other comments regarding nail fungus. In general, in my clinic I find it valuable to first confirm the diagnosis of nail fungus and then discuss any necessary treatment. Regarding the distribution of your nail changes, some patients may have athlete's foot and nail fungus in their toes, and with contact/itching, this can spread to involve the hands and fingernails over time.

pops502: Why do they say not to use butenafine hydrochloride cream (Lotrimin Ultra) for nail fungus?

Thomas_Knackstedt,_MD: While it is not specifically contraindicated, most creams to not penetrate the nail well enough to treat nail fungus. The use of dedicated topical medications that come either as an alcohol-based liquid solution or as a nail lacquer that is painted on appears to be more effective. However, nail fungus is oftentimes related to the surrounding athlete's foot, so feel free to treat the associated athlete's foot with Lotrimin.

Illness Indications

GJL56: Is there any nail condition that’s an indicator of cardiac issues?

Thomas_Knackstedt,_MD: Thank you for your question. In the majority of patients, there is no relationship between heart health and nail changes. "Terry's nails" refers to a white discoloration of the nail plate close to the nail folds. This may be associated with congestive heart failure, but has many other causes as well. These findings are rather nonspecific, and there are no unique nail changes that should prompt a work-up for heart troubles.

BettyBoop: What causes “clubbing” of the fingernails? Is it only respiratory conditions?

Thomas_Knackstedt,_MD: Nail clubbing has most classically been associated with a variety of lung conditions, including lung disease and lung cancer. Clubbing may also be associated with thyroid disorders. Importantly, most patients who have clubbing do not have a serious thyroid or lung condition. In fact, most patients I evaluate for clubbing do not meet the formal diagnostic criteria for clubbing and have other explanations for their nail changes.

m: What are some health conditions that can affect the nails?

Thomas_Knackstedt,_MD: Thank you for your question. Most nail changes are limited only to the nails without any associated systemic illnesses. However, nail changes can be seen with other health conditions. Rashes and inflammation on the skin due to lichen planus or psoriasis may also cause nail changes. Patients with chronic kidney disease may develop white or red discoloration of their nail plates. Individuals with advanced cancer receiving chemotherapy may have nail changes due to the chemotherapy they are receiving. Inflammatory conditions such as scleroderma or lupus may also affect the nails. Nevertheless, it is important to note that most nail changes are unrelated to overall health conditions.

mth2016: My right middle fingernail has an indented split straight from the bottom of the nail to the top. It seems to be getting wider. I know I hit the bottom of that nail a while ago, but this happened before, like a year ago. Then it healed almost completely. Now, it comes back after a bit. What could this be? I hope it is not SUBUNGUAL CUTANEOUS SQUAMOUS CELL CARCINOMA. On my left foot, the middle toenail is distorted, and there seems to be a cyst (bump, no pain) that drained clear gel twice. What could this be?

Thomas_Knackstedt,_MD: Thank you for this detailed question. Many different things can cause your nail to grow out with a line and a split. Most of these conditions are due to benign (noncancerous) growths of the nail. However, as you have already found in your own research, occasionally, such split lines are skin or nail cancers. In this case, I would recommend an in-person evaluation with a physician trained and experienced in nail diseases. Regarding your second concern, cystic lesions around the nail are common. Most often, these are digital myxoid cysts, which represent fluid collections. Oftentimes, these are related to underlying arthritis in the joints close to the nail. Most do not require treatment. Occasionally, these cystic lesions can push down or up onto the nail and cause the nail to grow out abnormally. In that case, evaluation by a dermatologist experienced in nail disease may be helpful, as many different treatments exist.

Batyah: Hello. I'm a 69-year-old, white female. For the last four or five years, the outer edges of my fingernails are lifting on-and-off. Sometimes they are OK, but sometimes they are lifted or some of them are lifted, causing my fingernails to be much shorter than their normal nail bed. I can live with it, but my fingernails don't look as nice as they used to; they look very short. I don't use any chemicals and don't spend much time with my hands in water. I have had pulmonary sarcoidosis for seven years (but have never been treated, never took prednisone, etc.). I take simvastatin, and I wonder if this is a side effect of the statin. My doctors gave me various topical medications for the fingernails – including antifungals, antibiotics and antivirals – but nothing helped. Testing the clippings and a biopsy didn't reveal anything abnormal.

Thomas_Knackstedt,_MD: Thank you for your message. Most often, there is no relationship between nail changes and other systemic conditions. As I discussed with another guest, statins usually do not cause nail changes. However, I advise any patient who has failed treatment with multiple therapies and has had normal testing to follow up with a dermatologist experienced in nail diseases.

Batyah: Can statins affect nails? Specifically, can they cause brittle fingernails or lifting of fingernails? If so, which statins and at which dose?

Thomas_Knackstedt,_MD: Thank you for your question. In general, I do not associate statins with nail changes. Most causes of brittle fingernails or lifted nails are not medication induced. In some cases, antibiotics such as doxycycline can cause lifting of the nails. Chemotherapy medication can also affect the nails. If the brittle nature and lifting is bothersome, a follow up with a dermatologist may be valuable.

Injuries and Ingrowing

MarselMT4: I have a painful ingrown toenail. What are my treatment options?

Thomas_Knackstedt,_MD: A number of conservative and surgical options exist for ingrown toenails. The first focus is identifying the cause for the ingrowing of the toenail and addressing this as much as possible. At the time of an office visit for ingrown toenails, several techniques can be demonstrated to help the nail plate that is growing into the skin to grow over the skin rather than into it. If this is unsuccessful or if the ingrowing is too severe or persistent, there are several small surgical procedures that can be done to improve the symptoms.

GJL56: Occasionally, my one toenail will fall off and then grow back normally. Should I be concerned?

Thomas_Knackstedt,_MD: Thank you for your question. This is a difficult situation to evaluate in the absence of more detail. There are many reasons for a nail to "fall off." Some of my active patients (especially runners) will periodically have their entire nail plate fall off and grow back normally. In some, this is due to a bruise or hematoma under the nail. Because a number of other growths in the nail unit can cause the nail to be lifted or fall off, such a specific situation may benefit from evaluation by a primary care physician or dermatologist.

GJL56: I tripped February 17 and stubbed my nail while it was in my shoe. It is black and blue underneath the nail. Should I see the podiatrist at this time, or will it grow out?

Thomas_Knackstedt,_MD: Bleeding under the nail frequently occurs with trauma. This is called a hematoma. In most cases, this will grow out over time. However, this takes quite some time, since the toenails grow approximately 1 millimeter per month. At that rate, it can take up to 12 months for a hematoma to completely grow out. While most hematomas are easy to diagnose, some patients may in fact have a brown/black growth under their nail rather than bleeding. When discoloration does not grow out over time, following up with a dermatologist experienced in nail disorders is recommended.


That is all the time we have for questions today. Thank you, Dr. Knackstedt, for taking time to educate us about Nail Health.

Thomas_Knackstedt,_MD: Thank you for the opportunity to speak with you all this afternoon. As we have discussed, the majority of nail changes are limited to the nails and are much less likely to be related to any other systemic illnesses or medical conditions. Most nail changes are not caused by medications. Importantly, in scenarios where only one nail is affected by a change or irregularity, it may be wise to seek follow up with a dermatologist. In settings where multiple nails are affected, this is often due to aging, fungal infections (especially on the toes) or inflammation in the nails due to a process such as psoriasis.

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The Department of Dermatology includes 35 Cleveland Clinic dermatologists who offer a full array of subspecialized care for adult and pediatric patients. Our physicians provide expert diagnosis and treatment of all disorders of the skin, hair and nails, whether primary or related to an underlying systemic illness, including industrial-related conditions. The department also offers a full range of procedures in the area of dermatologic surgery, including laser surgery, chemical peels, soft tissue augmentation, BOTOX injections, hair transplant, liposuction and Mohs micrographic surgery, which provides the highest cure rate for high-risk melanoma skin cancers while sparing the maximum amount of normal skin. Cleveland Clinic dermatologic surgeons perform more than 2,500 Mohs procedures each year. Additionally, our Cutaneous Care Center provides outpatient treatment, utilizing phototherapy and excimer laser treatment for patients with psoriasis and other chronic skin diseases.

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