Yellow nail syndrome



YNS has 3 classic findings—thick yellow nails, primary lymphedema, and pulmonary manifestations.


The diagnosis of yellow nail syndrome is one of exclusion and is made clinically based mainly on physical examination and radiographic findings. 



Differential diagnoses: planus lichen, chronic paronychia, and alopecia areata.



YNS may be caused by drugs or toxins: D-penicillamine, epoxy, chromium salts, and pesticides.



Infectious etiologies include: chloronychia caused by Pseudomonas aeruginosa, Candida, aspergillus, or dermatophytes.



Yellow nail syndrome is also associated with malignancy, connective tissue diseases, hemochromatosis, Guillain-Barré syndrome, myocardial infarction, diabetes, and thyroid dysfunction.



Proposed mechanisms of pathogenesis: 



Structurally, lymphatic hypoplasia and dilatation with collateral network



Functional disorder



Microvasculopathy causing protein leakage with impaired lymphatic drainage is thought to be the cause of lymphedema and pleural effusion formation.



Nail thickening may also be due to ectatic lymphatic vessels.



Nail discoloration may be due to lipid oxidation leading to an accumulation of lipofuscin in the nails.



Treatment for yellowing nails is: Oral vitamin E, zinc, triazole antifungals, and clarithromycin have all been used with varying results.



Antibiotics are used for acute bronchiectasis flares.



Surgical options for recurrent effusions include decortication/pleurectomy, pleural-peritoneal shunts, and chemical pleurodesis. 



Decortication/pleurectomy has the highest partial or complete response rate at 89%.



Lymphedema management: prevent infection, use of compression garments, regular exercises, overnight bandaging, and manual lymph node drainage can also assist with improving lymphedema. 



The treatment of sinusitis with antibiotics and possible surgical intervention if needed.



YNS nail changes may spontaneously resolve in about 30% of patients.



The remission of yellow nail changes does not imply  remission of other systemic manifestations, and further 


treatment of pulmonary and lymphedema symptoms may be necessary. 



Treating an underlying malignancy may lead to improvement in YNS in both signs and symptoms.



The median survival of patients with yellow nail syndrome is decreased by 132 months compared with a paired control population.




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