Introduction

Overview of Terry's nails

Terry's nails is a condition that is characterised with white nail beds and an apparent pink, red or brown band at the tip of the nails. The overall appearance of the nails not only change in colour but can also be distinguished by the form; thick and ridged nails with abnormal shapes are replaced with lunula-shaped nail beds and healthy cuticles.¹ This usually affects one or all of the hand nails although it is rare it can still be seen in fingernails. This condition is often associated with many systemic health conditions or aging in general. This includes conditions such as diabetes, predominantly seen in adults, cirrhosis of the liver, and chronic heart failure.²

Importance of identifying the underlying cause

It is important to find out the underlying cause of Terry’s nails to prevent further health complications. The diagnosis of Terry’s Nails can be tricky as it is often confused with Lindasy’s nails.³ Similarly, they both affect the appearance of the nails and are associated with health problems. Whilst Terry’s nails are caused by liver cirrhosis, Lindsay’s nails can be caused by kidney problems. Treatment of Terry’s nails can improve quality of life and prevent the condition from progressing to severe complications such as failure or organs. 

Causes of Terry's nails

Liver disorders such as liver cirrhosis are one of the main causes of Terry’s nails, poor blood circulation is often linked with white nail beds. Chronic conditions like liver failure are also associated with distortion of nail texture and colour. Terry’s nails, named after Richard Terry, a researcher that studied the whitening of nails and documented that 82 out of 100 patients suffered with liver cirrhosis, suggesting that it can be the most common cause of Terry’s nails.⁴ In addition, diabetes and kidney disease are the other known causes of Terry’s nails. Chronic kidney disease causes impaired blood flow around the body leading to white and pale nail beds which is the clinical representation of Terry’s nails. A study completed with approximately 512 hospitalized patients showed symptoms of Terry’s nails in which 25.2% of the patients were observed to have diabetes mellitus.⁵ Nevertheless, aging can lead to changes in nail appearance however, this may or may not be linked to chronic conditions. 

Diagnosis of Terry's nails

There are a few ways of diagnosing Terry’s nails, clinical examination by a physician is the most common way. A visual inspection of the fingernails is carried out to look for physiological changes. Discolouration of the nails is apparent, whitening of the nail bed with loss of lunula and change in colour is seen on the tips of the nails. Thick nail beds are also often seen in patients with Terry’s nails. A common misdiagnosis of Terry’s nails is true Leukonychia, it can mimic the condition due to similar clinical presentation which is white nail beds although Leukonychia is often associated with underlying inflammatory disorders unlike Terry’s nails.⁶

Fig 1. Is a patient with Terry’s nails. (A) representing colour discoloration with a pinkish/ brown band. (B) whitening of the nail bed is visible with rough texture. (C ) no appearance of lunula.⁷

A medical history review by a physician is also essential when diagnosing Terry’s nails to evaluate the potential underlying conditions. Other diagnostic testing can be done with blood tests to confirm any underlying condition. Liver function tests for cirrhosis and hepatic disease are used to confirm Terry’s nails, other laboratory tests that could be useful for diagnosing conditions affecting the nails are creatinine levels for renal function and hemoglobin levels.⁸ Imaging tests can also be preferred in situations where laboratory tests are insufficient. For example, ultrasounds are regularly used to check abnormalities in the kidneys. 

Treatment and management 

Treatment options 

There are various treatment methods available for Terry’s nails depending on the underlying condition. Taking medication, changing lifestyle, and receiving nutritional support are a few ways of managing Terry’s nails, however this is all specific to the health conditions below: 

Liver disease 

Liver cirrhosis is one of the main conditions behind Terry’s nails which is caused by consuming a lot of alcohol. Limiting alcohol may help manage the damage caused to the liver. The only treatment option currently available is liver transplant which is a complex procedure that has many disadvantages. 

 Kidney disease 

Chronic kidney disease can be treated by dialysis and kidney transplant. In early stages the management can be followed by controlling other underlying conditions; the most commonly found health condition is hypertension and diabetes. Maintaining a healthy blood pressure and glucose levels can delay the progression of chronic kidney disease.⁹

Heart-related diseases 

Treatment for heart failure includes taking specific medications to slow down the heart rate and relax the blood vessels.¹⁰ In complex cases, other medical procedures can help manage the condition. For example, a pacemaker which is a small device that is fitted into the patient through the veins. This device manages the heartbeat so that blood is pumped sufficiently.¹¹

Diabetes mellitus

Blood sugar control is the key for managing diabetes, insulin is the most commonly prescribed medication for diabetes. Additionally, lifestyle changes are essential; keeping a healthy diet, losing weight and increasing physical activity can help with the management of diabetes.

Symptomatic management 

Cosmetic interventions can help manage Terry’s nails appearance. Many ways include: Caring for the nails by avoiding harsh chemicals and using protective gloves to avoid irritants.¹² Applying a fragrance-free moisturizer would be beneficial to help soothe the nails and improve the look of the nails. Nevertheless, physical appearance of the nails can distress some patients and lead to psychological stress, maintaining nail hygiene and applying nail polish can help manage the condition. 

Preventive measures 

There are many ways to prevent Terry’s nails if this occurrence is through aging and there is no underlying condition. Keeping nails healthy by cleaning them thoroughly, avoiding biting or picking and trimming the nails straight to limit the chances of ingrown nails.¹³ Also, making changes to lifestyle by taking nutritional support can prevent Terry’s nails. Keeping a healthy diet alongside taking specific vitamins and minerals is a preventative measure. Zinc deficiency, in particular, is known to cause white spots (leukonychia) on the nail bed.¹⁴ Taking zinc and biotin supplements can improve the overall health of the nails. Additionally, high fibre intake and a prebiotic-rich diet can naturally lower the blood sugar levels, which helps with maintaining diabetes. 

Furthermore, regular medical check-ups for Terry’s nails is crucial for early diagnosis of underlying conditions. It is important to keep in mind that signs and symptoms of Terry’s nails are often associated with many health conditions. A family medical history could be useful to predict the potential risks of health conditions a patient could face. 

FAQs

Can malnutrition cause Terry’s nails?

Malnutrition can be one of the reasons Terry’s nails are caused, however it's not always the cause as liver diseases are the most common reason. 

Is Terry’s nails harmless?

Terry’s nails do not always suggest an underlying health problem but it is important to undergo medical examination in case there are other symptoms that are likely to be related to serious conditions.

Could anxiety cause Terry’s nails?

This is not true, as there is usually an underlying condition behind Terry’s nails. Although, anxiety could create rigid and brittle nails which could be misconception for Terry’s nails. 

How common are Terry's nails? 

Terry’s nails is a very common condition specifically, if you have underlying liver problems. 

When should I see a doctor?

Although there are no adverse symptoms of Terry’s nails, if the clinical presentation is observed then this should be checked out by a doctor to prevent and manage health conditions.

Summary 

The management of Terry’s nails is associated directly with the underlying condition. It is important to find out the root cause of this condition to effectively treat it. Diagnosis can often be difficult because there are no adverse symptoms of Terry’s nails other than visual changes seen in nails. Diagnosis is often missed due to the assumption that this condition occurs as a normal part of aging; however, this is not always the case and should be explored further with diagnostic testing. In this case early detection of an underlying health condition can help prevent serious cases and manage the condition effectively to improve quality of life. Monitoring the underlying conditions is also crucial for improving overall health, applying all treatment options can improve the appearance of Terry’s nails.