Overview

Terry’s nails are a nail disorder in which the nails have a whitish or pale characteristic, with a narrow gradient of pink or brown at the tip. Although this is commonly seen in systemic diseases, such as liver disease, heart failure and diabetes, its association with autoimmune diseases is also important, hence it is uncommon and rarely talked about. An autoimmune disease occurs when our immune system mistakenly attacks the body’s own tissues, resulting in chronic inflammation and damage to different organs of the body. 

Autoimmune diseases, including rheumatoid arthritis, psoriatic arthritis, lupus and scleroderma can cause various vascular and inflammatory alterations that affect the nails. Other autoimmune liver diseases (like primary biliary cholangitis and autoimmune hepatitis) also play their part by disrupting circulation and protein synthesis. Although not specific to autoimmune diseases, Terry’s nails can be a useful clinical sign. They are more likely to indicate further evaluation, particularly in patients with other autoimmune symptoms. Treatment of the underlying disease may also help to improve the appearance of the nails, although many of the changes are irreversible. Fortunately, awareness of nail abnormality may lead to early detection, and comprehensive treatment of an underlying condition.

What are Terry's nails?

Terry’s nails are a type of apparent leukonychia where most of the nail bed appears white or pale, with only a narrow pink or brown band at the tip. This nail abnormality was first described by Richard Terry in 1954 and is often associated with systemic diseases rather than primary nail disorders.¹

Characteristic appearance

• The majority of the nail is white, but there is a small, dark band at the tip
• The lunula (the half-moon at the base of the nail) is frequently indistinct or absent
• The nail may have a “hazy grey” appearance
• Typically affects all fingernails but may not involve toenails¹

Common causes and associated conditions

Terry’s nails are often linked to systemic conditions, particularly those affecting circulation and metabolism. Some of the most common associations include:

• Liver disease (especially cirrhosis)
• Chronic kidney disease
• Congestive heart failure
• Type 2 diabetes mellitus
• Ageing (can occur in healthy elderly individuals)
• Autoimmune diseases (such as rheumatoid arthritis and lupus)¹

Pathophysiology behind Terry’s nails

The exact mechanism of Terry’s nails is not fully understood, but it is believed to be related to:¹

• Nail bed vascular changes - Reduced blood flow leads to increased connective tissue, giving the nails a pale appearance
• Capillary abnormalities - Telangiectasias (small, dilated blood vessels) may develop at the tip of the nail bed, contributing to the pink band
• Systemic disease effects - Conditions like liver failure or diabetes affect protein synthesis, circulation, and fluid balance, which may alter nail colouration

Recognising Terry’s nails can provide valuable clinical clues for diagnosing underlying systemic diseases.¹

Autoimmune diseases associated with Terry’s nails

Several autoimmune diseases have been reported to be associated with Terry's nails, including:

Rheumatoid Arthritis (RA)

Terry's nails have been seen in some patients suffering from rheumatoid arthritis autoimmune disease. This is due to the chronic inflammation and vascular changes in this disease.

Systemic Lupus Erythematosus (SLE)

Lupus is another autoimmune disease linked with Terry's nails, in which immune-mediated damage to blood vessels and tissues could contribute to the nail changes.

Psoriatic Arthritis (PsA)

In psoriatic arthritis, there is systemic inflammation and vascular abnormalities. This is thought to be responsible for the nail abnormality observed in Terry's nails.

Scleroderma

Microvascular changes have been seen in scleroderma. Scleroderma is a condition identified by the thickening and hardening of the skin and connective tissues, which could be the reason for Terry's nails.

Autoimmune hepatitis

Autoimmune hepatitis is a liver disease that causes immune-mediated damage to the liver. It interferes with circulation as well as protein synthesis and eventually affects the appearance of nails.

Primary Biliary Cholangitis (PBC)

This condition also causes Terry's nails and has been reported as primary biliary cholangitis. This is an autoimmune disease that affects the liver, thus affecting blood circulation which further affects the liver's ability to synthesise proteins, and could be the reason for the changes in appearance of the nails.

Terry's nails, although not diagnostic of any single autoimmune disease, are associated with several diseases that have chronic inflammation and vascular abnormalities. Their presence may serve as an important clinical clue when diagnosing autoimmune diseases. However, the exact pathophysiology behind these associations is still under study, and more research is needed to fully understand how autoimmune diseases contribute to Terry's nails.²

Underlying mechanisms. Why do autoimmune diseases cause Terry’s nails?

The underlying mechanism is believed to involve changes in nail bed vascularity, possibly due to overgrowth of connective tissue, leading to the characteristic appearance. Nail bed biopsies have revealed telangiectasias in the distal band, supporting the role of microvascular alterations.¹

As Terry's nails have been linked to various systemic diseases, their direct associations with autoimmune diseases have not been still well-established. However, autoimmune conditions could cause vascular changes and connective tissue alterations, which might contribute to nail abnormalities.³

Clinical significance and diagnosis

1. Indicator of systemic disease - Terry’s nails may present an early clinical sign of underlying autoimmune conditions such as rheumatoid arthritis, systemic lupus erythematosus (SLE), and autoimmune thyroid diseases
2. Vascular and immune dysfunction - The nail changes occur and therefore result from immune-mediated vascular alterations and chronic inflammation, affecting nail bed circulation and therefore nail structure
3. Diagnostic clue - The presence of Terry’s nails in patients with suspected autoimmune disorders can guide further investigations, such as autoantibody testing and inflammatory markers
4. Prognostic value - Persistent nail changes may indicate disease progression or poor control of the autoimmune condition, emphasizing the need for ongoing monitoring
5. Reversibility with treatment - Addressing the underlying autoimmune disease with appropriate therapy (e.g., immunosuppressants, hormone replacement for thyroid disorders) may lead to improvement in nail appearance¹

Management and prognosis

Management of Terry's nails involves addressing the underlying systemic condition. In autoimmune diseases, this typically includes identifying appropriate medical therapy to control the autoimmune disorder. For example, in the case of autoimmune hypothyroidism, treatment is suggested for normalising thyroid function, which causes improvement in overall nail appearance.⁴

As treating the underlying autoimmune disease leads to improvement in nail changes, this response may vary among different individuals. Regular monitoring and collaboration with healthcare providers specialising in autoimmune disorders are essential for optimal management.⁴

FAQs

Why is it called a terry nail?

Doctor Richard Terry (1950), identified Terry's nails for the first time in a large number of chronic liver disease (cirrhosis) patients and then described the nail characteristic appearance of a white nail bed with the narrow pink band at the tip. He was the first who identified the connection between this nail change and underlying medical condition.

Can Terry's nails be harmless?

Terry's nails can be harmless, especially in older adults due to the natural process of ageing. In old age people, Terry's nail is a natural process because of reduced blood flow and changes in vascularity of the nail bed. However, it's necessary to focus on a person's health condition by consulting a doctor if any other symptom is present.

Can malnutrition cause Terry's nails?

Yes, malnutrition causes Terry's nails. If there is deficient intake in a healthy diet in which vitamins, protein and minerals are present. It will affect nail health by a forming white and opaque appearance of nails that are present in Terry's nails.

How does hypothyroidism cause Terry's nails?

Hypothyroidism could cause Terry's nails by slowing down the metabolism of the body which then affects blood flow towards the nail bed and, therefore, nutrient delivery towards them. This affects nail vascularity and its growth, changing nail color, and texture and forming a white, pale appearance of nails as shown in Terry's nail.

Can anxiety cause Terry's nails?

No anxiety or stress does not cause Terry's nail but it can cause other nail symptoms.

Summary

Terry's nail, in which there is a change in the nail appearance, causes the nail bed colour to change to white, opaque with a narrow pink band at the tip of the nail. This is due to underlying medical conditions in which systemic body effects are involved. Like other systemic conditions such as diabetes, and heart disease, terry nail is also associated with autoimmune disease which is uncommon and rarely talked about. Autoimmune diseases like rheumatoid arthritis, lupus, and Hashimoto's thyroiditis cause chronic inflammation and immune-mediated damage by affecting vascular changes and inflammation internally which therefore affect nail appearance. Overall nail appearance itself is not harmful but it is associated with systemic underlying health disorders, which can be resolved by primarily treating by a health consultant. Managing systemic disease causes partial or complete improvement in nail changes, though prognosis varies depending on disease severity and response to treatment.