What causes vertical ridges on nails?

Vertical Ridges on Nails: Causes and Clinical Significance

Vertical ridges running from cuticle to nail tip are most commonly a normal sign of aging as the nail matrix's ability to produce smooth nails diminishes, though they can also indicate inflammatory conditions like lichen planus or psoriasis. 1

Primary Causes

Normal Aging

• Vertical ridging represents the most frequent benign finding, occurring as the nail matrix loses its capacity to generate uniformly smooth nail plates with advancing age 1
• This physiologic change requires no treatment when occurring in isolation without other concerning nail features 1

Inflammatory Dermatologic Conditions

• Lichen planus produces nail plate thinning with subungual hyperkeratosis and prominent longitudinal ridging 1
• Psoriasis causes nail thinning and longitudinal ridging, often accompanied by other characteristic changes 1
• These inflammatory conditions damage the nail matrix, resulting in dramatically slowed growth and progressive ridging 2

Brittle Nail Syndrome

• Characterized by longitudinal ridging combined with splitting or brittleness of the nail plate 1
• May indicate underlying systemic conditions, medication side effects, or direct nail matrix damage 1

Chronic Trauma

• Repeated minor injury to the nail matrix causes permanent damage preventing normal nail plate formation 2, 3
• Occupational exposure and chronic moisture contact lead to proximal nail dystrophy with associated ridging 1

Infectious Causes

• Fungal infections (onychomycosis) cause nail thickening, discoloration, and friable texture that can present with ridging 1, 4
• Account for 15-40% of all nail diseases in adults 1
• Chronic paronychia from Candida infection leads to proximal nail dystrophy with ridging, particularly in patients with wet occupations 1

Diagnostic Algorithm

Initial Assessment

• Examine nail texture: Soft, friable texture suggests fungal infection versus hard, brittle texture of non-infectious causes 1
• Look for associated changes: Pitting, onycholysis, subungual hyperkeratosis, or discoloration suggest inflammatory disease rather than simple aging 1
• Assess for paronychia: Nail fold swelling or erythema indicates Candida infection, particularly with occupational moisture exposure 1

Laboratory Confirmation When Indicated

• Direct microscopy with potassium hydroxide (KOH) preparation and fungal culture on Sabouraud's glucose agar are essential if fungal infection is suspected 1, 4
• Calcofluor white staining enhances visualization of fungal elements 4, 2
• Critical pitfall: Do not diagnose fungal infection based on appearance alone—50% of dystrophic nails are non-fungal despite similar clinical presentation 1, 4

Management Approach

For Benign Age-Related Ridging

• Apply daily topical emollients to periungual folds, nail matrix, and nail plate to maintain hydration 1
• Use protective nail lacquers to limit water loss from the nail plate 1
• File nail surfaces gently with an emery board after softening in warm water 1
• Avoid trauma, nail biting, prolonged water soaking, and exposure to harsh chemicals 1

For Inflammatory Causes (Psoriasis/Lichen Planus)

• For involvement of fewer than 3 nails: Intralesional triamcinolone acetonide 5-10 mg/cc for nail matrix involvement 1
• Topical steroids with or without vitamin D analogs for nail bed involvement 1

For Confirmed Fungal Infection

• Treat with systemic antifungal agents (terbinafine or itraconazole) only after mycological confirmation 1
• Daily application of urea-based keratolytic cream to reduce nail thickness if needed 1

For Chronic Paronychia

• Keep affected area dry 4
• Apply topical povidone iodine 2% twice daily 4
• Provide occupational counseling—patients with chronic moisture exposure need guidance on protective measures like wearing gloves while cleaning 1

Common Pitfalls to Avoid

• Never assume fungal infection without laboratory confirmation—the nail surface in non-infectious conditions typically doesn't become soft and friable as in fungal infection 1
• Do not overlook occupational counseling for patients with chronic moisture exposure 1
• Recognize that medication-induced changes may require treatment modification rather than topical interventions alone 2