Review
Carpal tunnel syndrome and associated nail changes: Review and examples from the author's practice

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Carpal tunnel syndrome (CTS) is commonly seen by general practitioners and often presents with neurologic symptoms of nocturnal pain and paresthesia along the median nerve distribution. Approximately 20% of patients also present with cutaneous findings (ulcerations, blistering, sclerodactyly, nail dystrophy) characterizing a severe form called necrotic CTS. Necrotic CTS can also be associated with bone changes (acro-osteolysis). In the author's practice, combined nail and skin findings are not an uncommon presentation of CTS, although this form remains overlooked and underreported in the dermatological textbooks and studies. This manuscript aims to review the literature on CTS cases, with a specific focus on using associated nail findings as diagnostic clues. The literature review along with a few additional recent cases from the author's practice demonstrate that CTS is frequently accompanied by a variety of nail changes including koilonychia, longitudinal fissuring, Beau's lines, onychomadesis, melanonychia, nail thickening, hyperkeratosis, and ischemic ulcerations with paronychia. Furthermore, when these changes are limited to the second and third fingernails, they should prompt the diagnosis of CTS. Once suspected, diagnostic evaluation is not difficult and surgical management can resolve cutaneous findings and prevent irreversible changes such as acro-osteolysis.

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Methods

The PubMed database was searched for related literature using a combination of key words carpal tunnel syndrome, nail, nail changes, and nail dystrophy. All studies involving the effect of the CTS on nails were obtained, translated, and reviewed for evidence.

Results

Our search found 27 studies reporting 43 cases of cutaneous and nail changes as a consequence of CTS (Table I28, 29, 30). Approximately 72% of the patients were women (31/43), and the rest were men (12/43). The mean patient age was 54.27 years, and the greatest number of cases involved the right hand (19/43). In most cases, the nail changes involved the first, second, and third digits (26 times) or the second and third digits (19 times). A single digit was affected least often; the second digit

Discussion

The vasomotor dysfunctions of the median nerve as a consequence of its mechanical compression can lead to trophic changes of the skin and nails.9,32,33 In addition to mechanical compression,25 inadequate vascularization to the distal phalanges is also implicated.15 Vascular study results may be normal in some cases, possibly because of the low sensitivity of currently available capillaroscopy and photoplethysmography devices for detecting the minimal and/or temporary changes in the

References (46)

  • S. Aroori et al.

    Carpal tunnel syndrome

    Ulster Med J

    (2008)
  • F. Goodyear-Smith et al.

    What can family physicians offer patients with carpal tunnel syndrome other than surgery? A systematic review of nonsurgical management

    Ann Fam Med

    (2004)
  • C. Foti et al.

    Unusual presentation of carpal tunnel syndrome with cutaneous signs: a case report and review of the literature

    Immunopharmacol Immunotoxicol

    (2011)
  • I. Atroshi et al.

    Prevalence of carpal tunnel syndrome in a general population

    JAMA

    (1999)
  • E. Aratari et al.

    Carpal tunnel syndrome appearing with prominent skin symptoms

    Arch Dermatol

    (1984)
  • M. Bouvier et al.

    [Disfiguring ulcer forms of the carpal tunnel syndrome]

    Rev Rhum Mal Osteoartic

    (1979)
  • R. Treves et al.

    [Digital ulcerations during a carpal tunnel syndrome with Raynaud's syndrome]

    Rev Rhum Mal Osteoartic

    (1980)
  • S.K. Khan et al.

    Acral osteolysis in bilateral carpal tunnel syndrome

    J Radiol Case Rep

    (2008)
  • M. Natale et al.

    Ulcerative and mutilating variant of carpal tunnel syndrome

    Acta Neurochir (Wien)

    (2005)
  • D. Adoue et al.

    [Carpal tunnel syndrome with digital ulcerations in a patient with renal insufficiency on periodic hemodialysis]

    Ann Dermatol Venereol

    (1984)
  • N.H. Cox et al.

    Blisters, ulceration and autonomic neuropathy in carpal tunnel syndrome

    Br J Dermatol

    (1992)
  • R. Pfister

    [Clinical aspects of skin and nail changes in the carpal-tunnel syndrome]

    Hautarzt

    (1954)
  • G. Pavesi et al.

    Carpal tunnel syndrome presenting with prominent skin symptoms

    Ital J Neurol Sci

    (1988)

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    Funding sources: None.

    Conflicts of interest: Dr Tosti has served as a consultant for Almirall, Procter & Gamble, DS Laboratories, Monat, Pfizer, and Thirty Madison; on the advisory board for Leo Pharma; and as a principal investigator for Incyte, Aclaris, Lilly, and Nutrafol. Ms Egger has no conflicts of interest to declare.

    IRB approval status: Not applicable.

    Reprints not available from the authors.

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