Median Nail Dystrophy

Medically reviewed by Dennis A Porto, MD and The Dermatologists 

Median nail dystrophy is a split in the midline of the nail starting at the cuticle. The condition usually affects the thumb. It results from a temporary defect that interferes with nail formation.

What Causes Median Nail Dystrophy?

Median Nail Dystrophy is thought to be caused by microtrauma to the nail matrix. This refers to small, repeated injuries that can disrupt the normal growth of the nail. Common causes include:

Nail Picking: The most common cause of median nail dystrophy is nail picking, usually by the nail of the index finger on the same hand. The condition occurs more often during periods of stress.

Other causes include repetitive trauma such as overuse of cellphones and guitar playing.

This dystrophy can be similar to a habit-tic deformity, which means that it is caused by repeated back-and-forth picking of the nail.

This condition is also more common among patients with psychiatric diseases. In obsessive-compulsive disorder (OCD), the picking is part of a larger attempt to remove dirt and cleanse the skin. The patient is often unaware of the picking and performs the activity automatically.

Another factor that has been reported to cause median nail dystrophy is medication, such as oral isotretinoin.

Recognizing the Symptoms of Median Nail Dystrophy

While the most characteristic sign of Median Nail Dystrophy is a longitudinal ridge or split in the nail plate, other symptoms may include:

• Nail Thickening: The affected nail may become thicker than the others.
• Discoloration: The affected nail might change color, turning yellow, white, or other colors.
• Pitting: Small depressions or pits may appear on the surface of the nail.

The condition is marked by an “inverted evergreen tree” pattern with a midline split on the thumbnail. This canal-like split extends from the cuticle to the tip of the nail, with parallel lines in the center, giving the appearance of an inverted fir tree or Christmas tree.

The condition is usually symmetrical and most often affects the thumbs, although other fingers or toes may be involved.

Other Conditions with Similar Nail Symptoms

When diagnosing Median Nail Dystrophy, it’s essential to consider other conditions that may exhibit similar nail abnormalities.

• Psoriasis: This skin condition can also cause nail pitting, thickening, and discoloration.
• Lichen Planus: An inflammatory condition that can cause ridges or grooves on the nails.
• Onychomycosis: A fungal infection that usually causes thickened, brittle, and discolored nails.
• Eczema: This can cause rough and pitted nails.

Each of these conditions has distinct features that can help differentiate them from Median Nail Dystrophy.

Patient’s Experience with Median Nail Dystrophy: An Online Consultation Insight

Visual representation of Median Nail Dystrophy: Noticeable wavy ridges and uneven texture on the nail bed

User’s question:

My right thumbnail has these deep ridges and it doesn’t lie flat against the nail bed, making it look all wavy. It’s been like this for around 6 months, but now it’s really started hurting, especially where the nail connects to the fingertip skin. The whole nail feels sore when I touch it. What’s going on with it? Can I get a doctor’s take on this?

Online Dermatologists’ answer

Thank you for consulting with us about your nail condition. Based on the images and information you’ve provided, your symptoms could be indicative of a type of NAIL DYSTROPHY known as median nail dystrophy. This is commonly attributed to trauma to the nail matrix, and its distinct longitudinal splitting and horizontal lines give the nail a ‘fuzzy fir tree’ appearance. Habit-tic deformity, resulting from habitual picking at the nail margins, could also be a contributing factor. 

For a more in-depth evaluation to rule out benign growths under the nail or other underlying conditions, I would recommend consulting a dermatologist in person. In the meantime, it would be advisable to avoid any activities that could cause further trauma to the nail to promote healing.

What can I do?

Prevent picking your nails and stop the activities that may contribute to your median nail dystrophy. The condition usually improves over time, so no treatment is necessary.

Should I seek medical care?

Because median nail dystrophy usually heals on its own, but is not easily treated. If the condition persists and does not heal, your healthcare provider may try excision of the nail matrix abnormality after consultation.

This procedure involves surgically removing the affected portion of the nail matrix, though it comes with potential risks such as infection or altered nail growth.

Treating Median Nail Dystrophy

Median nail dystrophy can be very difficult to treat, as no therapy is consistently successful. If the cause is known, most cases of dystrophy resolve on their own within a few months after the discontinuation of activities that cause trauma on the nail.

Some cases have shown success in treatment with 0.1% tacrolimus ointment, applied on the proximal folds of both thumbnails without occlusion every night.

Surgical Intervention: In severe cases, the doctor might suggest a procedure to treat the nail matrix.

Consultation with a healthcare provider is essential to determine the optimal treatment approach.