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Hi Everyone,
I was wondering if anyone can shed some light on this. My patient is mid 40's and has paraplegia due to multiple sclerosis. He is a smoker. He has normal sensation in his feet and legs. His toenails have a strange appearance. They are brown distally and white on the proximal half. They are not friable, nor is there any onycholysis. Pathology has shown a negative result for any fungal elements. This colour change has occured in the last 6 to 12 months.
He is in no pain but we were wondering if it is due to his MS, or something else.
Thanks to anyone who can help.
Beth.

Having worked in a multiple sclerosis clinic and checking my files, I am not aware of any specific nail disorder that is pathognomic for MS - most do get some sorts of nail disorders for a range of reasons.

My first reaction is not to trust the pathology report - there are too many false negatives (I never use them for that reason)

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

Related threads:
Severe pain in MS foot-cuboid area
Foot orthoses and multiple sclerosis
Multiple Sclerosis, Chemotherapy and podiatric implications.

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Ifthe toenails are white proximally,you may have to start thinking HIV.Ask about thst discreetly.

Thanks Craig and John.
I'm always dubious about path results too. The GP ordered it. Doesn't have the texture or smell of a mycotic nail, and the white is not just superficial like in superficial white onychomycosis. Topical antifungals anyway??
I can make some more enquiries about medical history as suggested by John.
Patient is in care, and I only go there every six weeks but I'll see what else I can find out.
Thanks,
Beth.

Beth,you are welcome.I have not seen a patient who had onycho simply due to MS.

Change in nail appearance is more commonly due to trauma or pressure or ischemia.

Fungus comes after the nail has been weakened either by trauma or ischemia in a tight shoe.

In MS frequently the toes contract putting undo pressure in shoes on the nail matrix area. Once damage is done the nail will grow more friable, slower with ridges allowing air moisture and eventually fungus to get in. These are the reasons for the color change. Most damaged nails when cultured do not always yield a positive for TR.

Almost all women in the US have a 5th toenail that is misshapen and discolored. babies are not born with this deformity most men except for athletes, salesman, lawyers and business types that wear pointy shoes do not have this 5th toenail deformity.

Secondarily in women again the 1st toenail becomes damaged from shoe gear.

We as a profession need to stop trying to make money on "lasers" and discuss the real cause and as there is no cure for a permanently damaged nail the prevention.

Shoes for both sexes need to be shaped like feet duh.

Hi Beth,
I have seen a few MS folks over years and have come across a few where muscle contractions of foot and leg muscles that cause plantar and dorsi flexions of the feet and toes for abnormal durations and degrees cause abnormal pressure on bedding and footwear, this can result in changes in skin and nails. I have seen a distal dorsal hallux ulcer of longterm duration caused by this as well as altered nails
regards Phill Carter

Hi Beth,

MS is an autoimmune disorder in which the myelin nerve sheath is damaged. This explains the muscular contractures.

The disease also creates plaques in the white nervous tissue which affect the non-myelinated autonomic controlled vessels that cause vasodilation/vasocontraction.

Could blood supply to the germinal matrix explain the nail colouration/quality?

Or is the colouration really of the nail plate, or of the sterile matrix?

Hello Recent Posters,
Firstly, I'd like to thank you for your interest in this case.
This was a patient who I used to see in aged care, but I haven't been there for a few years now. I definitely remember his feet though.
Regarding questionable vascular supply as aetiology, it's possible. I remember him always having very cold feet, with oedema. But I never conducted a vascular assessment on him.
Contraction of the flexors, causing clawing and onycholysis could have been it, too.
Unfortunately I probably won't have an opportunity to see his feet again, as I'm avoiding aged care work to save my back.
Sorry I can't give you any more information.

Kind regards,
Beth.

PS: Hi Phil, it's good to hear from you? How's things in the countryside?

Hi Beth,
I love being where traffic lights are optional, and I am getting a nice mix of work, public, private, functional, wounds and of course the general foot care. I do miss some things about my previous life though....but I can come visit.
regards Phill