Introduction

Terry’s nails are a non-inflammatory nail abnormality characterised by a white or pale proximal nail bed and a narrow red proximal and distal red band. This condition was first described by Dr Richard Terry in 1954 and is associated with systemic diseases, especially liver disease, kidney failure, and diabetes mellitus.^1,2 One of the most frequently associated conditions among these is cirrhosis, as studies have demonstrated that Terry's nails might be a means for the detection of hepatic dysfunction clinically.

Cirrhosis is a chronic, progressive liver disease due to hepatic fibrosis, cellular damage, and altered architecture of the liver. Complications of the disease, such as portal hypertension, hepatic encephalopathy, coagulopathy, and hepatorenal syndrome, impose a large clinical burden.² With limited options for early detection of complications of cirrhosis, noninvasively measurable bedside assessments such as nail examinations have become an attractive idea in clinical practice.

This article discusses Terry's nails, the association between nail abnormalities and morbidity of patients with cirrhosis, and the possible clinical relevance of Terry's nails as a noninvasive marker of cirrhosis severity.

Pathophysiology of terry’s nails

Terry's nails are vascular, and structural changes in the nail bed blood vessels are secondary to systemic (whole body) blood circulation changes. The key underlying mechanisms include:

Microvascular alterations

One of the most plausible explanations for Terry’s nails is a dysfunction of blood circulation caused by cirrhosis. The liver plays an essential role in the regulation of systemic circulation through the production of vasoactive substances. The systemic vascular dynamics are also influenced by portal hypertension in cirrhosis that occurs as a consequence of increased intrahepatic resistance.^1,3 Changes in blood flow distribution to the nail bed due to these effects reduce blood flow to peripheral tissues. The condition is said to be caused by decreased numbers of capillaries in the tissues, resulting in pale skin near the nail and a brownish band further away to represent localised venous congestion.

Hypoalbuminemia and nail bed pallor

Patients with cirrhosis frequently have hypoalbuminemia from impaired hepatic protein synthesis.¹ Oncotic pressure and vascular integrity are maintained by albumin. Terry's nails are hallmarked by nail bed pallor due to reduced albumin levels, causing fluid shifts.

Increased vascular permeability

The increased vascular permeability of liver dysfunction causes oedema and extravasation of plasma into surrounding tissues.³ In addition, it may further affect the appearance of Terry’s nails by changing nail bed transparency as well as blood supply.

Differentiation from other nail abnormalities

Terry's nails are associated with cirrhosis; similar changes can occur in other conditions. In chronic kidney disease, Lindsay's (half-and-half) nails are more common, where the coils are more distinct and clearer with white and brown bands.1-3 Typically, Muehrcke's lines (appearing as paired white bands across the nail) are related to hypoalbuminemia rather than to cirrhosis itself. Terry's nails being present in a cirrhotic patient should raise further suspicion for complicating syndromes.

Cirrhosis-related complications and their association with terry’s nails

Terry's nail appearance in cirrhotic patients may be a surrogate marker of worsening liver function, and the presence of Terry's nails may indicate that the patient's liver dysfunction has worsened. Below are some key cirrhosis-related complications and their association with nails.

Portal hypertension and its manifestations

Portal hypertension, a major consequence of cirrhosis, results from increased resistance to blood flow in the hepatic portal vein. The resulting varices, ascites, and splenomegaly (enlarged spleen) make up this condition.^1,4 These complications, in addition to indicating disease progression, may also have systemic effects by causing alterations in nail morphology.

• OesophagalEsophageal Varices
  • Increased portal pressure directly leads to the development of oesophageal and gastric varices. It is hypothesised that the same vascular alterations implicated in developing varices may also have an effect on the nail bed and result in Terry’s nails.⁴ Terry's nails are due to what might also be called pallor plus localised whitening, which is explained (at least partly) by the microvascular changes that occur as a result of portal hypertension
• Ascites and hypoalbuminemia 
  • Decompensated cirrhosis is characterised by the presence of ascites, which is the presence of fluid in the peritoneal cavity. Terry's nails are strongly linked to the development of hypoalbuminemia, which is both a cause and a consequence of ascites.⁴ Terry's nails may be indicative of albumin depletion, which may contribute to albumin's role in maintaining oncotic pressure and vascular health more broadly

Hepatic encephalopathy

Hepatic encephalopathy  (HE) is a neuropsychiatric syndrome in which the accumulation of ammonia and other toxins results from impaired liver detoxification.

Neurological and peripheral manifestations

Patients with advanced HRV have flapping tremors (asterixis) and other disturbances in peripheral function, including changes in nail colour and texture. Widespread research on the correlation between Terry's nails and HE is limited; however, since cirrhosis has severe systemic implications, it might be related indirectly. Toxic buildup may lead to chronic vascular and metabolic problems at the nail bed level.

Coagulopathy and bleeding tendency

Because of reduced coagulation due to a lack of synthesis of clotting factors, cirrhosis is associated with impaired coagulation and an increased risk of bleeding.

Impact on nail bed perfusion

Nail bed colouration may be influenced by increased bleeding risk in combination with vascular fragility.⁴ Reports that Terry's nails are more pronounced in patients with significant coagulopathy, but this has not been proven. Nail bed discolouration is common in cirrhosis, as well as thrombocytopenia and endothelial dysfunction.

Hepatorenal syndrome

Progressive renal failure resulting from renal vasoconstriction is the hallmark of severe complications of cirrhosis known as hepatorenal syndrome (HRS).

Potential link to nail changes

Profound systemic hypoperfusion associated with HRS may exacerbate microvascular changes of the nail bed, therefore making Terry's nails more prominent. Nail pallor and the loss of visibility of the lunula may be further affected by reduced blood flow to peripheral tissues.

Malnutrition and micronutrient deficiencies

Protein-energy malnutrition resulting from cirrhosis usually results in poor skin, hair, and nail integrity.

Vitamin and mineral deficiencies

Deficiencies in zinc, iron, and biotin, which are common in cirrhotic patients, may explain nail abnormalities, notably in Terry's nails. Poor nail discolouration and fragility may worsen from zinc deficiency, which is particularly associated with poor wound healing and maintenance of epithelial tissue.¹ Because of other conditions, such as iron deficiency, the appearance of pale Terry's nails can get worse. Some of these changes may be mitigated by proper nutritional management.

Clinical utility of terry’s nails in cirrhosis

A Non-invasive diagnostic marker

Physical examination findings such as Terry's nails may thus contribute to disclosing valuable clues to early detection of cirrhosis-caused complications, given how difficult it is to diagnose them early. In settings with scarce resources where access to sophisticated imaging and laboratory tests is limited, the finding of Terry's nails may prompt clinicians to consider underlying hepatic abnormalities.⁴ The proximal whitening and distal band of normal colouration are characteristic nail changes that may be used as an external marker of systemic alterations of circulation and protein synthesis in liver disease. Knowing these signs may prompt early intervention and more evaluation of liver function.

Correlation with disease severity

Several research studies have confirmed a relationship between Terry’s nails and the seriousness of liver disease. 

MELD and Child-Pugh Scores: The presence of Terry's nails is a useful clinical sign, but it is not specific to cirrhosis. There can be other systemic diseases like chronic kidney disease, diabetes mellitus, and heart failure, which are also responsible for similar types of changes in the nails.^1-4 Some signs of this can include the appearance of the nails being changed due to nutritional deficiencies, ageing, and genetic factors. Therefore, his nails cannot replace standard diagnostic means but should serve as one of the components of the general evaluation of hepatic dysfunction, together with other diagnostic methods.

Limitations and confounders

Terry's nails are a useful clinical sign, but they are not specific for cirrhosis. Other systemic diseases, such as chronic kidney disease, diabetes mellitus, and heart failure, can yield similar nail changes. The altered appearance of the nails can also arise from nutritional deficiencies, ageing, and genetic factors. Therefore, Terry’s nails must not replace standard diagnostic means, but they must be used in conjunction with them as part of the general evaluation of hepatic dysfunction.

Summary

Proximal discolouration and distal brown discolouration of the nail (Terry's nails) are commonly seen in patients with cirrhosis. The mechanisms involved are microvascular dysfunction, hypoalbuminemia, and increased vascular permeability, all of the hallmarks of cirrhosis.

Terry's nails may suggest worsening liver function and are linked to major cirrhosis complications such as portal hypertension, hepatic encephalopathy, and hepatorenal syndrome. As this is not liver-specific, Terry's nails would give a non-invasive, simple, and obvious marker for early detection and risk stratification of cirrhotic patients.

Further research is needed to establish a relationship between Terry's nails and the progression of cirrhosis. Nevertheless, due to their clinical relevance, nail examination should be included in the routine examination of patients with suspected or known liver disease.