Introduction

Terry’s nails are classified as a distinct white opaque discolouration of the nails. They appear as all white or a pink/brown line at the distal portion of the nails. This can be seen as a side effect in various chronic disease states such as chronic kidney disease, liver cirrhosis, diabetes, heart failure, etc. It is typically not a severe condition, but it can be a good indicator of undiagnosed medical conditions.

Definition of terry's nails

‘Terry’s nails’ is defined as a white discolouration of the nails (leukonychia). In 1954, Richard Terry coined this term. He was the first to identify this abnormality of the nails in patients diagnosed with Liver Cirrhosis. Over the years, other nail-whitening abnormalities were discovered.

The initial whitening of the nail bed presents as ground-glass opacity with a 1–2 mm distal band of normal pink, which was described by Terry but was later revised to a distal band of 0.5 - 3mm present as pink or brown.³

Terry's nails can also be defined as a result of changes in the vascularity, a decrease in the nail area that is close to the skin end of the nail and an increase in the outer nail area (nail tip). This occurrence is commonly an indication of many systemic diseases that disrupt blood and fluid supply throughout essential parts of the body.

All fingernails are typically affected uniformly. This appearance reduces blood flow, capillary changes, and alters protein levels.

Appearance of terry's nails

It can be described as a pale or white nail plate with a narrow pink band at the tip. Normal nails show a consistent pink or brown colour with a clear lunula (the crescent-shaped area at the base) of the nail bed.⁴

Figure 1 below shows normal fingernails in a healthy individual with normal undertones of pink and a strip of white towards the proximal area close to the skin.

Terry's nails are not transparent or impossible for light to pass through (opaque) in appearance. They are characterised by a reddish or brown band strip at the distal portion of the nail beds, as presented below.

Causes and associated conditions

1. Liver Cirrhosis - It causes low levels of the proteins, albumin production by the liver, which is an important component of the blood supply in the body. Once the inability of albumin to produce red blood cells is affected, an individual becomes at risk of developing Terry’s nails
2. Heart failure -  Terry’s nails may develop due to reduced blood flow to the extremities. The condition reflects changes in vascularity and connective tissue within the nail bed, leading to the characteristic white appearance
3. Diabetes mellitus - Individuals with diabetes may experience changes in their nails due to neuropathy associated with poor blood circulation
4. Chronic kidney disease - ‘Terry’s nails’ can also indicate kidney malfunction, and the distortion depends on the severity of the malfunction
5. Bleeding: Studies have shown an incidence of Terry’s nails due to gastrointestinal bleeding, which causes a decrease in haemoglobin and leads to anaemia. Anaemia occurs when the blood doesn't have enough healthy red blood cells and haemoglobin (a protein found in red blood cells) to carry oxygen throughout the body
6. Hypothyroidism - Thyroid hormones play a role in the production of Keratin, which is an essential protein in nails. They are considered one of the key regulatory hormones for skin homeostasis. Multiple organs are affected by the release of peripheral thyroid hormones (T4 and T3), further regulating various functions at a cellular level⁷
7. Malnutrition - Poor blood circulation due to the absence of food in the body can contribute to the manifestation of Terry’s nails
8. Hepatitis C- It causes damage to the liver, which can cause Terry’s nails
9. Ageing - Although “ageing” isn’t a systemic disease, it can play a role in causing Terry’s nails due to physiological natural changes in the body. As we age, the nails become thinner and brittle over time due to the reduction of blood flow to the nail beds

Terry’s nails have also been reported in reactive arthritis, renal transplant patients, POEMS syndrome, cancer, and leprosy.¹¹

Diagnosis and clinical significance

Visual examination of the nails is the most efficient way of diagnosing Terry’s nails. Based on this, a physician can use this medium to run diagnostic tests for various systemic disorders listed above to narrow down the root cause.

Early detection of systemic disorders associated with Terry’s nails is a crucial factor in saving lives.

Differential diagnosis

Lindsay’s nails

There are other cases of (leukonychia), which may present in a similar format and can be misdiagnosed as Terry’s nails.

Lindsay’s nails, also known as (half-and-half nail), are differentiated from Terry’s nails and are characterised by both the proximal nail bed and distal nail bed being white and pink or brown bands occupying 20 % to 60 %.⁹

The proximal nail has a whitish ground, glass-like appearance, obscuring the lunula, and all nails are involved, as opposed to Terry’s nails, which present the distal portion of the total nail length to be less than 20% as seen in Figure 1.

Lindsay’s nail is typically found in patients with chronic kidney disease (CKD). The factors listed below could lead to its manifestation:

• Nutritional deficiencies: Disruption of electrolytes such as urea, calcium, and phosphorus, accompanied by a compromised kidney function, can affect the skin, nails and hair
• Anaemia: CKD can lead to anaemia, which reduces oxygen delivery to the blood vessels and tissues, causing pale or brittle nails
• Toxin accumulation: When the kidneys can no longer filter body waste properly, it can cause a build-up in the bloodstream, hence affecting the appearance of the nails
• Protein loss: In advanced kidney disease, protein loss through urine (proteinuria) can lead to low blood levels of albumin

Treatment and management

Although there is no specific treatment for Terry’s nails themselves, some lifestyle changes may help during the treatment and management process.

Addressing the root cause

• Thorough screening by a physician determines the underlying systemic condition/disease and treats it appropriately.

Nail care

• Effective nail and cuticle care
• Frequent use of creams and moisturisers to avoid dryness and peeling
• Avoid any potential irritants such as nail polish, artificial nails, nail glue, etc
• Practice good hand hygiene by washing with non-hazardous products
• Be careful with nail clippers and nail files to avoid injuries
• Avoid nail biting and gnawing at hangnails
• Protect your nails by wearing gloves at all times while using hazardous products

FAQs

Q1 - What causes terry’s nails?

Answer - This is a condition of the nails caused by a form of systemic disorder that affects the production and distribution of oxygenated blood through the body, giving the nails a white appearance with a small band of pink or brown at the distal portion of the nail bed.

Even though Terry’s nails are generally not harmful, it is advised to seek medical attention for a thorough medical checkup to identify any underlying conditions. Some examples of screening to be done should include, but not be limited to, signs of diabetes and kidney failure, congestive heart failure, or liver disease.

Q2 - How can I prevent terry’s nails?

Answer - There are no documented methods of preventing Terry’s nails; however, by making a few adjustments to your lifestyle, you can enhance the general health of your nails.

Also, make an appointment with your primary care doctor if you notice any abnormal changes in your fingernails.

Summary

Terry's nails are associated with a white, opaque, ground gloss appearance and about a 20% pink to brownish transverse band of the distal nail bed. 

This condition is usually associated with a pre-existing systemic medical condition such as liver cirrhosis, congestive heart failure, hypothyroidism, diabetes and chronic kidney disease. Age is also one of the major factors in the presentation of Terry’s nails.

There is no cure for Terry’s nails; it is practically an identifier of other comorbid diseases. Hygiene and diagnostic tests for root cause detection can allow the patient to get rid of Terry’s nails.