Onychogryphosis - Ram's Horn Nails

Some people have an overgrown nail on the great toe which can actually begin to curl as it continues to grow without being clipped. Also known as “Ram’s Horn Nails” because of the way it looks, Onychogryphosis is an abnormality characterized by thickening and overgrowing of the nail.

The nail texture is so thick that clipping it with a regular nail cutter is impossible. If left alone, the nails grow well beyond the nail bed and end up curled like claws. The individual will require a chiropodist or podiatrist to treat the nails. Removal of the nail may also be required periodically to manage the disorder.

Causes of Onychogryphosis

Congenital

Onychogryphosis is an autosomal dominant disorder. This means that if either one of the parents suffers from this disorder the child is likely to inherit it. The gene associated with the primary genetic defect is located on chromosome 4q33-q34. The mutations in this gene are the reason for the disorder.

The onset is generally seen during puberty if the characteristic signs are missing at birth. Children may also be born without nails altogether when it is congenital. Eventually when the nails grow, they may be stained a dark brownish shade.

The nails are also projecting upwards from the nail bed rather than lying flat like healthy nails do.

Acquired

A tendency to neglect the care of nails can also cause onychogryphosis. It is commonly associated with the homeless, people who suffer from dementia, and the elderly who tend to be forgetful about self-care. It can also be found in people who may have suffered a physical trauma to the nails because of their choice of incorrect footwear.

Anomalies in the position of the feet may promote this condition. Women often develop Onychogryphosis due to faulty shoes, which inflict stress on the nails. Negligence can lead to severe nail problems.

Existing Disease

Patients suffering from diseases such as psoriasis, ichthyosis, hystrix, hallux valgus, elephantitis, hyperuricemia, and other epidermal dysplasia may develop Onychogryphosis as a side effect of the other bodily changes occurring.

It is particularly common in those individuals suffering from peripheral circulation disorders and diseases of the central nervous system, both of which tend to affect the growth of nails.

Symptoms of Onychogryphosis

Early manifestation of the disorder may be  hypertrophy of the nail plate. The enlargement of the tissues here is often ignored and the nail beds can become quite damaged due to the uncontrolled growth of the nail.

The signature overgrowth of the nails may not be seen very quickly if the individual is careful in maintaining personal hygiene. It is the elderly who are usually affected because they are more negligent of their grooming.

A yeast or fungal infection of the nail bed is often a secondary symptom associated with the disorder. There may be itching of the skin along the nail accompanied by a fairly unpleasant odor. The long, thick curled nails which resemble the horns on a ram’s head are quite typical of the disorder.

Managing Onychogryphosis

Proper and timely care of the nails is vital for treatment to be successful. There are essentially two parts to handling Onychogryphosis - the first is to treat the nail bed deformity and the second is to treat the retracted dorsal skin next to the nail.

The nail bed deformity is generally treated by first surgically removing the nail. The avulsion of the nail will usually allow the nail bed a chance to repair the damage as it grows a new nail.

Ablation of the nail matrix with the use of a carbon dioxide laser is recommended. The new nail growth should be pared and trimmed regularly till the thickening of the nails reduces.

The treatment of the retracted dorsal skin next to the nail would involve skin grafting. A thumb nail may be treated by using a graft from the great toe, or vice versa. A flap of skin would be applied to the finger or toe that is being treated. The ablation or surgical removal of body tissue will include a vascularised nail graft.

At times avulsion of the nails is followed by scraping of the nail beds and the root. This may destroy the nails completely and is only done when the thickening is so bad that despite repeated clippings the nail refuses to return to its normal, healthy state. It is felt that the individual would do better with no nails rather than the diseased ones which require so much care and maintenance. An option many elderly people would prefer.

The individual will require regular visits to a chiropodist or podiatrist to treat the disorder. Besides the physical removal of the nails, they may also be given topical creams or ointments to apply to the affected area. In case of secondary infections, oral medication may also be prescribed. Regular reviews will be scheduled to ensure that the Onychogryphosis is treated until completely healed.

Reviewed by Afsaneh Khetrapal, BSc (Hons)

References

Last Updated: Jan 4, 2017

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