What is the significance and treatment of vertical and horizontal ridges in nails?

Vertical and Horizontal Ridges in Nails: Significance and Treatment

Vertical and horizontal nail ridges have distinct clinical significance, with vertical ridges often representing normal aging changes while horizontal ridges typically indicate more serious systemic disruptions requiring medical evaluation. 1

Vertical Ridges

Significance

• Vertical ridges running from cuticle to nail tip are primarily a normal sign of aging as the nail matrix's ability to produce smooth nails diminishes 1
• Can also be associated with inflammatory conditions like lichen planus or psoriasis, causing nail thinning and longitudinal ridging 1
• Onychorrhexis (longitudinal ridging with splitting or brittleness) may indicate systemic conditions, medication side effects, or nail matrix damage 2
• May be familial in some cases, presenting as an inherited trait 3

Treatment

• Daily application of topical emollients on periungual folds, nail matrix and nail plate 2, 1
• Use of protective nail lacquers to limit water loss and strengthen the nail plate 2
• Avoid nail trauma, excessive water exposure, and harsh chemicals 2
• For inflammatory causes like psoriasis or lichen planus affecting <3 nails:
  • Intralesional triamcinolone acetonide 5-10 mg/cc for nail matrix involvement 4
  • Topical steroids with or without vitamin D analogs for nail bed involvement 4

Horizontal Ridges (Beau's Lines)

Significance

• Horizontal ridges or depressions across the nail plate typically indicate a temporary disruption in nail growth 5
• Often associated with:
  • Systemic illness or severe stress 6
  • Medication side effects, particularly from cancer therapies 4
  • Nutritional deficiencies 6
  • Trauma to the nail matrix 5

Treatment

• Address the underlying cause of the disruption 5
• For medication-induced horizontal ridges:
  • Daily dilute vinegar soaks to nail folds twice daily for 10-15 minutes 4
  • Mid to high potency topical steroid ointment to nail folds twice daily 4
  • Consider temporary dose adjustment of causative medication in consultation with prescribing physician 4

Diagnostic Approach

When to Suspect Fungal Infection

• Thickening, discoloration, and friable texture of nails 4, 1
• More commonly affects toenails than fingernails 4
• Requires confirmation through:
  • Direct microscopy with potassium hydroxide preparation 4
  • Fungal culture on Saboraud's glucose agar 4
• Treatment with antifungal agents if confirmed 4

When to Suspect Systemic Disease

• Multiple nails affected simultaneously 6
• Associated with other skin or systemic symptoms 6
• Sudden onset of nail changes 5
• Nail changes accompanied by pain or inflammation 5

Prevention Strategies

• Apply daily topical emollients to cuticles and periungual tissues 2, 1
• Avoid excessive moisture exposure 2, 1
• Wear gloves while cleaning or working with chemicals 1
• Maintain good nail hygiene to prevent secondary infections 1
• Avoid repetitive trauma to nails 2

Special Considerations

• Nail changes that are asymmetric, rapidly progressive, or associated with pigmentation should prompt evaluation for malignancy 5
• In children with nail abnormalities, consider familial conditions 3
• Single nail involvement with longitudinal ridges and splitting may indicate localized conditions like lichen striatus 7
• Malalignment of nails can lead to ridging due to repeated microtrauma 8