Published on 18/03/2015 by admin
Filed under Dermatology
Last modified 22/04/2025
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Robert L. Baran
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
The yellow nail syndrome (YNS) is an uncommon disorder of unknown etiology characterized by the triad of yellow nails, lymphedema, and respiratory tract involvement. This term was originally used to describe the association of slow-growing yellow nails with primary lymphedema. Pleural effusion was later recognized to be an additional sign of the syndrome. Since then, other respiratory conditions, such as bronchiectasis, sinusitis, bronchitis, and chronic respiratory infections have been associated with the disorder. Although all the three signs that classically characterize the triad of YNS do not occur in every patient, the presence of typical nail alterations should be considered an absolute requirement for the diagnosis. The complete triad is seen in 25% of patients, lymphedema in 40%, and pleural effusions in only 2% of patients with yellow nails. A variant of yellow nails can also be seen in HIV infection.
Although YNS may resolve spontaneously, treatment is often sought by sufferers. The yellow nails are unsightly, discolored, hard, show transverse over-curvature, and are slow growing. Paronychia and onycholysis can be observed.
Underlying diseases such as respiratory disorders, malignancy, infections, immunologic and hematologic abnormalities, endocrine, connective tissue and renal abnormalities, and miscellaneous disorders, including penicillamine therapy, should be sought. Titanium or titanium dioxide may cause YNS. Improvement of any underlying disorder (e.g., lymphedema) may also result in improvement of the nail plate.
There are no large series or randomized trials in the treatment of YNS. Oral vitamin E has been used as monotherapy. The oral azole antifungals itraconazole and fluconazole have also been reported to be effective, both alone or in combination with vitamin E. The combination of fluconazole and vitamin E is currently the best treatment for curing the nail unit. This was confirmed by anecdotal reports that supplement our own findings. Matrix steroid injections have been successfully employed. Octreotide, zinc, and medium chain fatty acid triglyceride supplements as well as clarithromycin have been used in anecdotal reports.
Attention to the diseases underlying yellow nails is mandatory but does not always result in resolution of the nail dystrophy. Therapies that effect resolution of the nail changes in yellow nails may have no effect on the associated pathology.
Rule out nail fungal or Pseudomonas infection
Complete blood count
Urinalysis, proteinuria
Immunoelectrophoresis
Thyroid-stimulating hormone
Serum rheumatoid factors
Chemistry profile with blood creatinine
Sinus and chest radiography
ENT and pulmonary investigations
Liver enzymes, alkaline phosphatases
T and B cell deficiency
There are anecdotal reports of YNS with tuberculosis, solid carcinoma, and lymphomas, etc.
Baran R, Thomas L. J Drugs Dermatol 2009; 8: 276–8.
Complete cure has been obtained in 18–24 months in 11 of 13 patients. However, there is still a wide discrepancy between the response of the nail to treatment and the remaining signs, which are usually unimproved.
Hawasie K, Pope E. Pediatr Dermatol 2010; 27: 675–6.
A single report using fluconazole 200 mg once weekly and oral vitamin E 1000 IU daily with success in an 8-year-old girl.
Iheonunekwu N, Adeyo O, Clare A, Cummings C. West Ind Med J 2011; 60: 99–101.
A further report of combination oral fluconazole and vitamin E in an adult with yellow nails
Gupta S, Samra D, Yel L, Agrawal S. Scand J Immunol 2012; 75: 329–35.
Immunoglobulin administration resulted in the decreased frequency and severity of infections, and an impressive effect was observed on lymphedema and on the recurrence of pleural effusion.
Berglund F, Carlmark B. Biol Trace Elem Res 2011; 143: 1–7.
The role of titanium ions released through the galvanic action of dental gold or amalgam or through the oxidative action of fluorides has been emphasized. In other patients, the titanium was derived from titanium dioxide in drugs and confectionery.
Samman PD. Trans St John’s Hosp Dermatol Soc 1973; 59: 37–8.
Repeated intradermal trimacinolone injections in the proximal nail matrix may be very effective on the nail unit.
Suzuki M, Yoshizawa A, Sugiyama H, et al. Case Rep Dermatol 2011; 3: 251–8.
This paper describes a dramatic improvement of the yellow nail discoloration and growth of nails in a patient.
Fournier C, Just N, Leroy S, Wallaert B. Rev Mal Resp 2003; 20: 969–72.
Besides the nail manifestations, the patient had bilateral bronchiectasis. Daily physiotherapy with bronchial drainage led to a progressive improvement in the respiratory signs. The nail abnormalities disappeared after 2 years of treatment.
Szolnoky G, Lakatos B, Husz S, Dobozy A. Int J Dermatol 2005; 44: 501–3.
Manual lymphatic drainage was performed on each leg for 45 minutes and multilayered compression bandaging was subsequently applied. This was repeated daily for 2 weeks, except at weekends, when the compression was not accompanied by massage. The edema reduction and the increase in lymph flow were associated with an improvement in the appearance of the toenail plates. Fingernails failed to show any change.
Arroyo JF, Cohen ML. Clin Exp Dermatol 1992; 18: 62–4.
Total resolution of yellow nails and lymphedema was observed following oral zinc supplementation for 2 years.
Gocmen A, Kucukosmanoglu O, Kiper N, Karaduman A, Ozcelik U. Turk J Pediatr 1997; 39: 105–9.
Low-fat diet supplemented with medium chain triglycerides brought moderate improvement in the lymphedema of the lower extremities.
Makrilakis K, Pavlatos S, Giannikopoulos G, Toubanakis C, Katsilambros N. Ann Intern Med 2004; 141: 246–7.
Octreotide, a somatostatin analogue, was effective in a classic case of YNS, with yellow nails, lymphedema of lower extremities, and recurrent chylous pleural effusion.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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α-Tocopherol + fluconazole
Treatment of the concomitant disorder
Stopping galvanic release of titanium ions.
Intradermal triamcinolone injections to the proximal nail matrix
Clarithromycin
Physiotherapy
Oral zinc supplementation
Dietary treatment
Octreotide treatment
