6.3 Nail Disorders and Diseases: Signs, Symptoms, and Referral
Key Takeaways
- A manicurist recognizes signs and symptoms and refers; a manicurist does not diagnose or prescribe as a physician.
- Infectious nail disease (onychomycosis/tinea unguium, paronychia, onychia) is a refuse-and-refer situation, not a longer soak.
- Pyogenic granuloma and undiagnosed or inflamed nail psoriasis are refer-out conditions, even though psoriasis is not a fungus.
- Cosmetic or noninfectious disorders such as onychophagy with intact skin, leuconychia, many hangnails without infection, and brittle plates may be serviced with caution.
- Onycholysis, onychocryptosis, pterygium, eggshell nails, and bruised nails are judged by pain, infection, and broken skin — when in doubt, do not service and refer.
Disorder, infectious disease, and cosmetic condition
NIC Domain 2 asks you to recognize signs, symptoms, and causes of disorders, diseases, and conditions of the nails. Arkansas still licenses you as a manicurist, not as a physician. Three labels keep you out of trouble:
- A disorder is an abnormal nail condition. It may or may not be infectious. Onycholysis (plate separating from bed) is a disorder with many possible causes: trauma, product, thyroid disease, psoriasis, or infection underneath.
- An infectious disease is caused by a pathogen. Onychomycosis and tinea unguium are fungal. Paronychia and onychia are typically bacterial (sometimes mixed). These spread on implements and in water if you ignore infection control.
- A cosmetic condition is an appearance issue without a contagious disease process — polish stain, a healed bruise growing out, leuconychia white spots from a minor matrix bump, onychophagy (bitten nails) with intact skin.
Your job: see the sign, name it in classroom language, decide service / modify / refuse / refer, and never announce a medical diagnosis as if you were writing a chart in a clinic. Saying “these signs match what our textbook calls onychomycosis; I cannot service this nail; please see a physician” is recognition plus referral. Saying “you have fungus, here is a prescription cream” is practicing medicine.
ADH establishment rules also keep people with communicable disease out of service. You do not need a lab culture to refuse a obviously infected, draining nail. You need the courage to stop.
Infectious and inflammatory emergencies
Onychomycosis is fungal infection of the nail unit. Signs: thickened, brittle, crumbling plate; yellow, white, or brown discoloration; debris under the plate; odor; a plate that looks “chewed” from within. Cause: dermatophyte or other fungi in a moist, sealed space. Service: refuse the affected nails. Refer. Do not file clouds of infected keratin across the salon. Do not trap debris under a tip “to hide it.”
Tinea unguium is ringworm of the nail — the classroom name many items still use for dermatophyte nail infection. Treat it as onychomycosis for service decisions: refuse and refer. It is not “dry toenails.” It is not a stain you buff off.
Paronychia is inflammation of the tissue around the nail (the perionychium), often after a torn hangnail, aggressive cuticle work, or wet work. Signs: redness, heat, swelling, pain, and often pus. Cause: usually bacteria entering a break in living skin. Refuse and refer. Do not “drain it” with a pusher. Do not continue an e-file cuticle clean-up.
Onychia is inflammation of the matrix, often with pus, and it can lead to shedding of the plate. Signs: pain at the base, swelling, discharge, a plate that loosens from the proximal end. Refuse and refer. You cannot disinfect a matrix infection with polish.
Pyogenic granuloma is a refer immediately lesion: a lump of red, raw, easily bleeding tissue growing from the nail bed or fold, often after injury. It is not a polish blob. It is not a hangnail. Do not service. Do not pick. Refer.
Disorders you must still sort into service versus refer
Onycholysis is separation of plate from bed, usually starting at the free edge and moving back. The detached plate looks white or yellow because air and debris sit where the bed used to show pink. Causes: injury, overly aggressive cleaning under the nail, product lifting, psoriasis, thyroid disease, or infection in the space. If the area is clean, painless, and clearly a small mechanical lift, some textbooks allow careful cosmetic work on remaining attached plate without sealing debris into a pocket. If you see odor, debris, discoloration of infection, pain, or you do not know the cause, refer and do not apply enhancements over a hollow.
Onychocryptosis is an ingrown nail. The plate pierces the living lateral fold. Mild, not infected, not deeply embedded: you may file the offending corner without digging into living tissue and refer for medical care if it is more than a cosmetic edge. Red, swollen, draining, or a client who wants you to “cut it out”: refuse and refer. You are not performing nail surgery.
Onychophagy is nail biting. Bitten plates and ragged free edges can still receive a manicure if the skin is intact. Open, raw, bleeding, or infected folds: stop and refer. Do not lecture the client as a substitute for infection control.
Onychorrhexis is split, brittle nails with lengthwise ridges. Often from solvents, injury, or aging keratin. Oil manicures and gentle shaping are the usual cosmetic plan when there is no infection. Sudden severe change plus other body symptoms: refer rather than selling a miracle oil.
Leuconychia is white spots or white streaks. Minor matrix trauma is the usual classroom cause. Can service. Do not call it calcium deficiency as a diagnosis.
Hangnail (agnail) is a split of living skin beside the nail. If small and not infected, nip the dry strip with disinfected nippers — do not rip. If the fold is red, hot, or pus-filled, you are looking at paronychia: refer.
Pterygium after scarring: do not tear. Cosmetic oil will not dissolve scar. Refer when it is medical or you would have to cut living tissue to “clean it.”
Eggshell nails: thin, flexible, white. Gentle service if intact; no aggressive thinning; condition; avoid heavy enhancements that the plate cannot support. Refer if you suspect systemic disease the client has not had evaluated — you still do not diagnose it.
Bruised nail: trapped blood. Gentle service if painless and not infected; refer if painful, swollen, or draining.
Psoriasis of the nail is a skin disease that can pit the plate, leave salmon-colored “oil drop” patches, cause onycholysis, and crumble the plate. It is not tinea unguium, even when it looks crumbly. It is not contagious in the fungal sense, but it is medical. Inflamed, broken, or undiagnosed: do not service; refer. Do not soak a psoriatic hand in a community pedicure tub as if it were ordinary dry skin. Do not tell the client you will “cure psoriasis” with oil.
Service versus refer table
| Condition | Classic signs | Usual cause family | Service or refer |
|---|---|---|---|
| Onychomycosis / tinea unguium | Thick, crumbly, discolored, debris, odor | Fungal infection | Refuse and refer |
| Paronychia | Red, hot, swollen fold, often pus | Bacterial infection of surrounding tissue | Refuse and refer |
| Onychia | Painful matrix, pus, possible plate shedding | Infection/inflammation of matrix | Refuse and refer |
| Pyogenic granuloma | Red bleeding lump from bed or fold | Inflammatory lesion after injury | Refuse and refer |
| Nail psoriasis | Pitting, salmon patches, crumbling, skin plaques elsewhere | Medical skin disease, not fungus | Refer; no service on inflamed/broken skin |
| Onycholysis | Plate lifting from free edge | Trauma, product, disease, or infection | Refer if unknown, painful, or infected; do not seal debris |
| Onychocryptosis | Ingrown plate in living fold | Mechanical + fold injury | Refer if infected or embedded; do not cut living tissue |
| Pterygium (scar) | Skin stretched onto plate | Matrix/eponychium scarring | Do not tear; refer if medical |
| Onychophagy | Bitten plates | Habit | Service if skin intact; refer if infected |
| Onychorrhexis / brittle | Split, dry, ridged | Keratin damage, solvents, aging | Service; oil manicures; refer if sudden systemic change |
| Leuconychia | White spots | Minor matrix injury | Service |
| Hangnail (agnail) | Split living skin | Dryness, trauma | Nip if not infected; refer if paronychia |
| Eggshell nails | Thin, flexible, white | Under-built plate | Gentle service if intact |
| Bruised nail | Dark patch under plate | Blood from trauma | Gentle service if painless; refer if painful/infected |
Exam traps
Trap: treating psoriasis as fungus because both can crumble. Trap: diagnosing tinea unguium out loud and selling a drug. Trap: continuing a manicure through pus because the client “only has 20 minutes.” Trap: cutting an ingrown nail out of the fold. Trap: calling pterygium “cuticle.” Trap: oil manicure as infection prevention — classroom teaching recommends oil for brittle nails, not as an antiseptic.
Scenario: two feet, two decisions
A walk-in wants a polish change. The right great toenail is thick, yellow, and crumbling with debris (textbook tinea unguium / onychomycosis). The left fingernails are short from biting but the skin is closed (onychophagy). The Arkansas manicurist refuses the diseased toenail, does not file the crumbly keratin, explains that a physician must evaluate infection, and may still perform a careful finger manicure on intact skin. That split decision is the whole chapter: recognize, stay in scope, beautify what is healthy, and refer what is disease.
A client's toenails are thick, yellow, and crumbling, with packed debris and a musty odor. What is the correct first professional action for an Arkansas manicurist?
After a client ripped a hangnail, the proximal fold is red, hot, swollen, and leaking pus. What is the correct decision?
Several fingernails show pitting, salmon-colored patches, and crumbling, and the client also has scaly plaques on the elbows. What is the best professional response?