What causes vertical nail ridges and how are they treated?

Vertical Nail Ridges: Causes and Management

Vertical nail ridges are most commonly a normal manifestation of aging and typically require no treatment unless associated with pain, rapid changes, or signs of underlying disease. 1

Primary Causes

Normal Aging (Most Common)

• Vertical ridges running from cuticle to nail tip represent the most frequent presentation, occurring as the nail matrix's ability to produce smooth nail plates diminishes with advancing age 1, 2
• These longitudinal striations are a benign finding in elderly patients and generally don't require treatment unless causing functional problems 1

Inflammatory Dermatologic Conditions

• Lichen planus affects nails in approximately 10% of cases, causing thinning of the nail plate, longitudinal ridging, subungual hyperkeratosis, and potentially dorsal pterygium 3, 1
• Psoriasis produces nail changes including ridging, often accompanied by pitting and other nail manifestations 3, 1
• Darier disease, a rare genetic disorder, can cause nail dystrophy with prominent ridging 3, 1

Occupational and Traumatic Factors

• Repetitive trauma to the nail plate results in abnormal nail appearance including ridging 3, 1
• Excessive moisture exposure, particularly in occupations requiring frequent hand washing or water immersion, contributes to nail changes 1
• Chronic paronychia from wet occupations leads to proximal nail dystrophy with associated ridging 2

Critical Differential Diagnoses

When to Suspect Infection

• Onychomycosis presents with thickening, discoloration, and soft/friable nail texture—distinctly different from simple ridging 3, 1
• Fungal infections more commonly affect toenails than fingernails and typically involve multiple nails 3
• Bacterial infections (particularly Pseudomonas) cause green or black discoloration and may coexist with fungal infections 3, 1

Red Flags Requiring Further Investigation

• Sudden appearance or rapid change in ridging pattern warrants medical evaluation 1
• Associated pain, inflammation, or nail separation suggests active pathology rather than benign aging 1
• Single nail involvement may indicate trauma, tumor, or localized infection 3

Diagnostic Approach

Clinical Examination

• Assess all 20 nail units to determine pattern of involvement (isolated vs. multiple nails) 1
• Look for associated skin conditions (psoriatic plaques, lichen planus lesions) that might explain nail changes 1
• Examine for intact longitudinal epidermal ridges stretching to the lunula in trauma cases 3, 1

Laboratory Testing (When Indicated)

• Direct microscopic examination with potassium hydroxide preparation if fungal infection suspected 2
• Fungal culture on Sabouraud's glucose agar for definitive identification 2
• Nail biopsy reserved for suspected inflammatory conditions or malignancy 4, 5

Management Strategy

Conservative Management (First-Line)

• Daily application of topical emollients to cuticles and periungual tissues helps prevent and manage nail changes 3, 1, 2
• Gentle nail care including avoiding cutting nails too short and regular trimming to keep them straight 3
• Wearing gloves while cleaning or working with chemicals prevents further damage 3, 1, 2
• Avoiding excessive moisture exposure and wearing comfortable, well-fitting shoes with cotton socks 3

Treatment of Underlying Conditions

• For inflammatory causes (psoriasis, lichen planus affecting <3 nails): intralesional triamcinolone acetonide 5-10 mg/cc for nail matrix involvement, or topical steroids with/without vitamin D analogs for nail bed involvement 2
• For confirmed fungal infection: systemic antifungal therapy with terbinafine or itraconazole 2, 5
• For medication-induced changes: daily dilute vinegar soaks for 10-15 minutes twice daily, mid-to-high potency topical steroid ointment to nail folds twice daily, and consideration of temporary dose adjustment in consultation with prescribing physician 2

Key Clinical Pitfalls

• Do not assume all nail dystrophy is fungal—the nail surface in fungal infections becomes soft and friable, unlike the hard ridges of aging or inflammatory conditions 3
• Avoid empiric antifungal treatment without confirmatory testing, as studies demonstrate cost-effectiveness of testing to prevent inappropriate therapy 5
• Remember that clinical improvement with topical antifungals may not equal mycological cure, with cure rates often 30% lower than clinical improvement rates 3
• In elderly patients, vertical ridges are typically benign—reserve aggressive workup for cases with concerning features 1