Introduction

Terry’s nails were first noticed by Dr Richard Terry in 1954.¹ He noticed that over 82 out of 100 individuals with scarring on their livers had changes to their nail colours.

Today, we know that Terry’s nails is a condition that affects the skin beneath fingernails.¹ If someone has Terry’s nails, most of the nail is very pale. The only part of the nail which keeps its colour is a thin strip at the top of the nail.

This usually happens to several nails, but sometimes it only affects the nail on one finger, and people often say that it makes the nails look like frosted glass. It can happen on either the toenails or the fingernails, and it is a form of leukonychia, which is the medical term for the fingernails becoming pale.

Terry’s nails can be an important sign of other health conditions, so they are important in helping diagnose other medical problems.¹

Anatomy and pathophysiology of terry's nails

It is useful to know the normal anatomy of the nail so that it’s easier to spot when something goes wrong.

We will start by talking about the nail features that are closest to the palm of the hand, moving away to the tip of the finger.

Proximal nail fold

The proximal nail fold is the bump of skin that is between the cuticle and the rest of the hand.

Eponychium

This is usually called the cuticle, a thin layer of skin that sits on top of the bottom part of the nail.

Lunula

This is a half-moon-shaped pale area at the base of the nail.

Nail plate

The nail plate is the fingernail itself. The skin beneath the nail plate is what is pale in Terry’s nails.

Lateral nail folds

The skin on either side of the nail plate is known as the paronychium, or lateral nail folds.

Distal edge of nail plate

This is the tip of the nail, which you trim. 

We do not know for certain what causes Terry’s nails, but it is thought that loss of the blood vessels under the skin below the nail is what leads to the paleness.

Systemic conditions associated with terry's nails

There are several health problems that make it more likely that a person will develop Terry’s nails. These include:

Liver disease

Cirrhosis is the name for scarring of the liver. This scarring is from the liver damaged over long periods of time. If this goes untreated, it can cause liver failure.

People with cirrhosis may have problems like:

• Red patches on the palms of their hands
• Feeling weak
• Burst blood vessels on the skin of the body above the waist level
• Tiredness
• Nausea (feeling like you’re going to vomit)
• Jaundice
• Reduction in libido (also known as sex drive)
• Blood in vomit
• Buildup of fluid in the legs or stomach, which causes swelling, itching, and bruising
• More than normal, dark urine
• Bleeding more easily than normal
• Dark poo
• Loss of appetite

Terry’s nails have been found in over 80% of people who have cirrhosis.² Hence, checking an individual’s hands may be a good first step in diagnosing liver problems.

Reactive arthritis

Reactive arthritis, which is also known as Reiter’s syndrome, happens when a person’s joints become sore after an infection. People who have reactive arthritis often describe:

• Feeling extremely tired
• Joints being painful
• Joints swelling bigger than their usual size, with red-hot skin over the top of the affected area, and becoming stiff
• Ulcers in the mouth
• Irritated eyes
• Pain when urinating
• Yellow pus coming from the palm of the hand or sole of the foot with flaking skin over the top
• Pale rash on the penis.

People with reactive arthritis may also have Terry’s nails.²

Diabetes

Studies show that people who develop diabetes in adulthood are more likely to have Terry’s nails.²

Diabetes occurs when the body cannot control how much sugar is in the blood. This can lead to health problems, including heart problems, nerve issues, eye health trouble, and damage to a person’s feet.

Tuberculosis

Tuberculosis is an infection caused when tuberculosis bacteria get into the lungs. People with tuberculosis can experience symptoms like feeling unwell (malaise), a cough that stays for more than three weeks, losing weight, coughing up blood, feeling really tired, a fever, and night sweats. Another symptom of tuberculosis can be Terry’s nails.² 

Kidney problems

Chronic kidney disease (problems with your kidneys which last a long period of time) can cause problems for the patient which include:

• Blood in urine
• Feeling exhausted
• Nausea (like you’re going to vomit)
• Swelling on feet, hands, and ankles
• Gasping for breath

Kidney issues can also make someone develop Terry’s nails.²

Heart failure

If the heart cannot pump well enough to get blood around the body, this is known as heart failure. People with heart failure may notice swelling in their legs or ankles, have difficulty catching their breath, faint, and feel exhausted. People with heart failure often experience Terry’s nails.³ 

Hepatitis

“Hepatitis” is the word that doctors use when a person’s liver has become inflamed, usually because of a virus infection. People with hepatitis often say that they have painful joints, yellowing of the skin (jaundice), itching, a fever, poo that is a pale grey colour, nausea and vomiting, urine that’s darker than usual, a feeling of extreme tiredness, pain in the stomach, a feeling of being generally run down, and being unable to eat.

If someone has hepatitis, they are more likely to have Terry’s nails.¹ 

Normal aging

Some people get Terry’s nails as part of the body getting older, which is completely normal.²

Treatment for terry’s nails

Terry’s nails are usually a sign of other problems, and so the best treatment for Terry’s nails is to treat the health issue. You should speak to your doctor to make a plan that can help to treat your health problem. Terry’s nails often go away once the problem is treated.

Differential diagnosis

Many health problems can cause whiteness on the fingernails. These can include:

• Damage to the nails, for example, by biting or knocking them, is the most common cause of fingernail whitening
• Lindsay’s nails are another condition where the nails change colour, but they are half pink or brown and half pale (rather than a small strip of colour in Terry’s nails). This usually happens in people with kidney disease⁴
• Darier’s disease is a skin condition that is very rare. It makes the skin thicker and can cause white patches on the fingernails
• If you are allergic to something that you put on your nails, like nail varnish, this can make your body create white spots on the fingernails
• Bart-Pumphrey syndrome can cause white fingernails, as well as deafness and thickened skin⁵
• Chemicals can cause the nails to go white, from anti-bacterial medications to chemotherapy to arsenic and lead.

Can I avoid terry’s nails?

There isn’t a definite way to make sure that you don’t get Terry’s nails, but there are steps that you can take to help keep your nails healthy. Some of these steps are:

• Use shoes that fit your feet well so that your nails do not get damaged by being squashed
• Do not bite your nails
• When you cut your toenails, cut straight across (rather than curving) to reduce the chances of an ingrown toenail
• Do not pick your nails
• Use gloves when you are using chemicals, for example, cleaning supplies, so that your nails are protected
• Use a soft brush to clean your nails
• Keep your nails moisturised by using a gentle, perfume-free hand lotion

Summary

Terry’s nails are a condition that affects the skin beneath fingernails. In Terry’s nails, the toenails or fingernails appear pale or frosty, with only the top of the nail retaining its original colour. It can be caused by many different health problems, including liver disease, reactive arthritis, diabetes, tuberculosis, kidney problems, heart failure, hepatitis, or just normal ageing. Hence, Terry’s nails can indicate or help diagnose an underlying health condition. This nail condition can be treated either by addressing the health condition or by taking steps to keep your nails healthy.