Yellow Nail Syndrome
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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Yellow nail syndrome (YNS) is a rare disorder, in which there is a triad of:
- Nail discolouration and nail dystrophy.
- Chronic respiratory disorders
It was first described by Samman in 1964.
It is very rare with only around 150 published cases.Men and women are equally affected.[1, 2]
- Both familial and sporadic cases have been reported.
- YNS has been classified as a dominantly inherited lymphoedema with variable expression. However, this classification and aetiology have been disputed, suggesting it may not be a genetic disease.[4, 5]
- The cause and underlying pathogenesis of the nail changes are unknown.
- The cause of lymphoedema is unknown, but the lymphatic abnormality may be congenital or acquired, or related to associated conditions. It may be caused by structural or functional abnormality.
- It usually presents between the fourth and sixth decades.
- The different clinical features of the syndrome may occur at wide intervals. Patients may not present with the classical triad of symptoms.
- Typically, the nails are slow-growing with a yellowish discoloration. They may appear to have stopped growing. They appear thicker.
- Usually nails remain smooth, but there may be ridging, overcurvature or loss of cuticles
- All nails may be affected.
- Onycholysis may affect one or more nails.
- Swelling occurs in around 80% and most often affects the legs.
- Hands, face and genitals may be affected.
- It is non-pitting.
- Lymphoedema typically occurs after the nail changes, often after an interval of some months.
Various respiratory conditions may occur:
- Pleural effusions most commonly (usually an exudate), which may be recurrent or massive:
- Secondary to infection
- Chronic sinusitis.
- Bronchial hyper-responsiveness.
- Recurrent pneumonia.
Associated clinical features
The following have also been reported; note that these are case reports only, so the link to YNS is uncertain:
- Chylous ascites.
- Intestinal lymphangiectasia.
- Non-immune hydrops and chylothorax in a fetus and neonate whose mothers had YNS.
- Thyroid abnormalities.
- Immunological abnormalities - eg, immunoglobulin A (IgA) deficiency.
- A number of other associations have been reported, but all are likely to be spurious.[1, 2]
Assessment and diagnosis[1, 6]
- The diagnosis is made clinically, once other causes have been excluded.
- Be aware that the different clinical features of the syndrome may occur at wide intervals.
- The absence of nail changes does not exclude the diagnosis, if other causes of pleural effusions and lymphoedema have been excluded.
There is no specific treatment for YNS. Standard treatments can be used for lymphoedema, pleural effusions and bronchiectasis. In addition, the following treatments have been reported as helpful in individual cases:
For nails[3, 7]
- Nail changes may resolve spontaneously without treatment.
- Topical vitamin E (in dimethyl sulfoxide); both ingredients seemed helpful.
- Oral vitamin E supplementation.
- Oil applied to the nails (in this case, topical vitamin E was not beneficial).
- Itraconazole pulse therapy.
- Oral zinc supplementation.
Oral zinc supplementation.
For pleural effusions
- Medical treatment:
- Diuretics and low-fat diet are possible treatments, but may be inadequate. (A low-fat diet with added medium-chain triglycerides reduces the load on the lymphatics, because medium-chain triglycerides are absorbed into the portal venous system, whereas long-chain fatty acids are absorbed into the intestinal lymphatics.)
- Octreotide, a somatostatin analogue, has been used successfully to treat chylous pleural effusion.
- Surgical treatment may be required:
- Pleurodesis or pleurectomy.
- Pleuroperitoneal or pleurovenous shunt.
- Massive pleural effusions can be life-threatening.[10, 11]
- Surgical treatment of pleural effusions may have complications:
- A pleuroperitoneal shunt led to severe oedema and abdominal distention in one reported case.
- Pleurodesis can lead to hypoventilation.
- Repeated loss of chyle from drainage of the pleural effusions can lead to malnourishment.
- Lymphoedema can affect quality of life.
- Nail changes may resolve in up to half of cases.
- Respiratory changes are usually manageable with medical and surgical regimens. Progressive respiratory insufficiency is uncommon.
- The most problematic manifestation seems to be large, recurrent pleural effusions.
Further reading and references
Gregoriou S, Argyriou G, Larios G, et al; Nail disorders and systemic disease: what the nails tell us. J Fam Pract. 2008 Aug57(8):509-14.
Maldonado F, Ryu JH; Yellow nail syndrome. Curr Opin Pulm Med. 2009 Jul15(4):371-5. doi: 10.1097/MCP.0b013e32832ad45a.
Maldonado F, Tazelaar HD, Wang CW, et al; Yellow nail syndrome: analysis of 41 consecutive patients. Chest. 2008 Aug134(2):375-81. doi: 10.1378/chest.08-0137. Epub 2008 Apr 10.
Yellow nail syndrome; DermNet NZ
Hoque SR, Mansour S, Mortimer PS; Yellow nail syndrome: not a genetic disorder? Eleven new cases and a review of the literature. Br J Dermatol. 2007 Jun156(6):1230-4. Epub 2007 Apr 25.
Yellow Nail Syndrome; Online Mendelian Inheritance in Man (OMIM)
Simon RW, Bundi B; Yellow nails, chronic cough, and edema. Am J Med. 2010 Feb123(2):125-6.
Lambert EM, Dziura J, Kauls L, et al; Yellow nail syndrome in three siblings: a randomized double-blind trial of topical vitamin E. Pediatr Dermatol. 2006 Jul-Aug23(4):390-5.
Tanaka E, Matsumoto K, Shindo T, et al; Implantation of a pleurovenous shunt for massive chylothorax in a patient with yellow nail syndrome. Thorax. 2005 Mar60(3):254-5.
Hillerdal G; Yellow nail syndrome: treatment with octreotide. Clin Respir J. 2007 Dec1(2):120-1. doi: 10.1111/j.1752-699X.2007.00022.x.
Razi E; Familial yellow nail syndrome. Dermatology Online Journal 2006, 12 (2):15.
Yamagishi T, Hatanaka N, Kamemura H, et al; Idiopathic yellow nail syndrome successfully treated with OK-432. Intern Med. 200746(14):1127-30. Epub 2007 Jul 17.