Pathogenesis, Clinical Signs and Treatment Recommendations in Brittle Nails: A Review
Nail plate brittleness (or fragility) is a common complaint affecting up to 20% of the population, especially women over 50 years of age, with fingernail fragility being more prevalent than toenail fragility. Nail brittleness is characterized by nails that split, flake and crumble, become soft and lose elasticity. The main clinical presentations are: onychoschizia, onychorrhexis, superficial granulation of keratin and worn-down nails. According to causative factors, we can distinguish 2 forms of nail fragility (NF): a primary “idiopathic or brittle nail syndrome” form and NF secondary to different causes such as inflammatory nail disorders, infections, systemic diseases and general conditions, traumas and alteration of the nail hydration. Optimal management requires treatment of the primary cause of brittle nails, when possible. In idiopathic NF oral supplementation, vitamins (especially biotin, also known as vitamin B7), trace elements and amino acids (especially cysteine) have been reported to be useful. In addition, several products, such as topical moisturizers and lacquers could be considered to restructure the affected nail plate and to reduce psychological impacts of this common problem.
KeywordsAging Onychoschizia Onychorrhexis Nail brittleness Nail cosmetic Nail fragility
Key Summary Points
Why carry out this study?
This review explores and updates the topic of brittle nails, a common condition and a frequent cause of dermatological consultation, providing comprehensive details about clinical presentation, pathophysiology and treatment options.
What was learned from the study ?
Optimal management of brittle nails requires treatment of the primary cause, when present, added to protective measures and bio-mineral supplementation. In addition, several topical products could be considered to improve nail plate fragility and reduce the physical and psychological impacts of this common problem.
Nail plate (NP) brittleness (or fragility) is a common complaint affecting up to 20% of the population, especially women over 50 years of age, with fingernail fragility being more prevalent than a toenail fragility .
Nail brittleness is characterized by nails that split, flake and crumble, become soft and lose elasticity. The main clinical presentations of brittle nails (BN) that have been described are: onychoschizia, onychorrhexis, superficial granulation of keratin and worn-down nails. Different signs of nail brittleness (NB) can be present alone, together in the same patient and together in the same nail plate. BN are generally not painful, but affected patients often complain of significant cosmetic and functional problems such as impairment in performing daily or occupational activities . Pain may occur from deep splitting and catching everything. In a cross-sectional study, the perception of BN was even associated with a depressed mood .
This review explores and updates the topic of BN, providing comprehensive details about clinical presentation, pathophysiology and treatment options.
Data Source and Search Strategy
We collected all studies related to BN indexed in PubMed from its inception to 31 August 2019. Search parameters included the following words or sentences: “brittle nails”, “nail fragility”, “etiology of brittle nails”, “onychoschizia”, “onychorrhexis”, “worn down nails”, “keratin granulation”, “therapy of brittle nails” and “treatment of brittle nails”. Only articles in English were included. All papers included in this study involved human or animal clinical studies, including case reports, case series and reviews. A subsequent review of the respective reference sections of the articles aimed to identify any undetected reports.
This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors.
The objective of this search was to analyze and document a review of the literature to propose some guidelines for the treatment of this disease.
BN may be a consequence of factors that alter nail plate production and/or factors that damage the NP.
Under physiologic conditions the NP is a fully keratinized structure made up of about 25 layers of tightly packed keratinocytes, with a thickness of 0.5–1 mm and a smooth surface. The majority of the NP derives from the proximal nail matrix (NM) and around 1/3 by the distal matrix and bed. The NM is localized under the proximal nail fold. Epithelial growth and keratinization of NM keratinocytes follow an oblique axis; during this process of maturation and differentiation cells move upward and distally. Normal nail growth is highly dependent on vascularization and inflammation [4, 5]. Impairment of this process results in NP abnormalities.
The clinical aspects of NB due to NM damage can vary depending on the site and the extent of the injury. NP thinning due to proximal NM damage always involves the whole nail length and is often associated with abnormalities in the superficial NP. Damage to the distal matrix, on the other hand, may produce alterations in the shape of the NP free edge, but not of the superficial NP.
BN may be caused by several factors: first of all, a physiological increased nail fragility is typical of aging. Other local or systemic causes include inflammatory nail diseases, onychomycosis, systemic conditions, medication ingestion, and trauma (occupational and professional). When a secondary cause has not been identified, the disease is defined as idiopathic.
- 1.Onychorrhexis: particularly frequent among middle-age women and characterized by longitudinal splitting and shallow parallel furrows running on the superficial layer of the nail (Fig. 1). The severity of the clinical presentation depends on the degree of the causative factor on the NM. Longitudinal ridges may vary from a few superficial ridges up to deep furrows, affecting from a small part of the nail surface to at least 70% of the total nail surface. Likewise, longitudinal splitting may vary from a few superficial splits up to multiple deep fissures. A single longitudinal split of the entire NP is sometimes observed (split nail) (Fig. 2). The pain induced by the deep splits may be the cause for medical advice being sought.
- 2.Lamellar onychoschizia: caused by the impairment of intercellular adhesive factors of the NP. As a result, the NP exfoliates into fine horizontal layers (Fig. 3). Nail hardness is mainly secondary to high sulphur amino acids, particularly cystine, and tight keratin cross-links. The keratin protein in nails is hardest at a slightly acid pH. Adhesion between cells is facilitated by membrane-coating granules with linkage by lipids, such as acyl ceramides. Triangular pieces of NP may easily be torn off from the free margin (crenellated splitting). In other cases, breaking of the lateral edges could cause transverse splitting. This type of nail fragility is almost exclusive to fingernails and it is typical of patients who wash their hands too frequently (e.g., homemakers, but also doctors and nurses). Proximal lamellar splitting may occasionally be observed in lichen planus or during etretinate or acitretin therapy.
- 3.Superficial granulation of keratin is a brittleness confined to the dorsal NP, not to be confused with superficial white onychomycosis. Superficial granulation of keratin is often reported in patients wearing nail polish for months, sometimes applying it over the previous coating. In this way NP keratins undergo to a gradual ‘granulation’ or exfoliation with the formation of small white-yellow patches and striations (Fig. 4). Keratin degranulation is a type of pseudoleukonychia, where the white discoloration of the nail is due to white particles (the damaged onychocytes) on the NP surface.
According to causative factors, we can distinguish 2 forms of NF: a primary “idiopathic” form and NF secondary to different causes.
Idiopathic Nail Brittleness (Brittle Nail Syndrome)
This is the most common cause of NB, almost exclusively seen in the fingernails. In women, the intercellular keratinocyte bridges are constitutionally weaker than in males and this can be considered a cause of the higher frequency of this complaint among females. Moreover, normal nails contain 5% lipids and there is a decrease in cholesterol sulphate of the NP with age, especially in post-menopausal women, suggesting an important role of lipids in the development of NB . Some authors have identified reduced water content in the nail plate (< 16%) as a possible cause of BN . In contrast, other studies found no significant difference in water content of brittle compared with normal nails [7, 8].
Secondary Nail Brittleness
Inflammatory Nail Disorders
Several dermatoses such as psoriasis, lichen planus, lichen striatus, alopecia areata, Darier’s disease and eczema may involve the nail apparatus [9, 10]. Usually these disorders are diagnosed as separate entities although features of nail fragility are common in these patients.
Several infectious diseases such as syphilis and pulmonary tuberculosis can give nonspecific alterations to the nails such as nail thinning and fissuring of the free margin and an overall fragility [16, 17].
Systemic Diseases and General Conditions
The impairment of peripheral circulation secondary to arteriopathy, neurological disorders, chronic anemia and arteriosclerosis may lead to a reduced NM vascularization with production of a thin NP .
Patients with endocrine disorders may present with BN, slow nail growth and longitudinal ridging and fissuring. Nail changes, characterized by brittleness and softness, are present in about 5% of cases of hyperthyroidism and are often reversible following successful therapy. The nails are affected in 90% of patients with hypothyroidism and typically appear thin, brittle, slow-growing and with longitudinal or transverse striae .
Onycholysis, increased fragility, longitudinal ridging and crumbling may occur in amyloidosis.
Systemic medications such as cancer chemotherapeutic agents, retinoids or antiretrovirals may be responsible for lamellar onychoschizia.
A severe deficiency of vitamins, trace elements and aminoacids from daily food intake may result in NF and thinning .
Traumas and Alteration of Nail Hydration
Finally, occlusive gloves applied over wet hands while working may be a cause of BN, leading to splintered, fractured nails and onychoschisis .
Treatment: Facts and Controversies
Secondary NB should be treated by acting, when possible, on the primary cause. In these cases, treatment includes the cure of the dermatological/systemic condition, avoidance of traumas and allergens/irritants, limiting contact with water and detergents, and regular use of emollients . However, most patients consulting for NB have an idiopathic NF. Oral supplementation with vitamins (especially biotin, also known as vitamin B7), trace elements, and amino acids (especially cysteine) have been reported useful in improving idiopathic fragility [24, 25, 26]. However, these studies were small, not well controlled, and one study was retrospective, survey based.
Takes part in keratin biosynthesis and intercellular cement holding keratinocytes together, acting as the prosthetic group of several essential enzymes;
Improves the ultrastructure of the NP (onychocytes show more regular arrangements and distribution) and its resistance to tension.
Several studies have demonstrated, both with clinical and electron microscopy examinations , an improvement of firmness and hardness of the fingernails of patients receiving biotin supplementation [28, 29, 30]. A dosage of 5–10 mg a day for 3–6 months is usually recommended.
High biotin intake (more than 10 mg per day) can cause falsely high or falsely low laboratory test results (FDA safety communication) . Troponins, thyroid, prolactin and pregnancy tests are some of the most frequently altered [32, 33, 34]. The presence of biotin can interfere with tests that use biotin–streptavidin technology. The interaction between biotin and streptavidin is used as the basis for many biotin-based immunoassays, and these immunoassays are vulnerable to interference when they are used to analyze a sample that contains biotin. The FDA warning on this topic emphasizes that physicians should obtain an updated list of medications, including vitamins and supplements, and doses, at each visit . This is particularly important as patients are not aware of the risks associated with biotin .
A combination of an arginine silicate complex and magnesium biotinate (a novel well-absorbed biotin salt) was demonstrated to increase nail growth . However, the studies were small and two of them lacked a control group .
Primary and secondary zinc deficiency is a cause of NF. Prolonged treatment with zinc 20–30 mg/day seems to be effective in improving BN .
In a recent randomized trial, a biomineral formulation containing amino acids (l-cystine, l-arginine, glutamic acid), vitamins (C, E, B6 and biotin) and minerals (zinc, iron and copper) proved to be well tolerated and effective in strengthening and smoothing fingernails in subjects with onychoschizia after 3 months of treatment . No data about dosage of the single elements is provided in the article .
In an open-label single-center trial, supplementation with “bioactive collagen peptides” was shown to be very effective in patients with BN after 24 weeks of treatment. In this study it was reported that nail growth rate increased by 12% and the frequency of broken nails decreased by 42% .
Nail moisturizers are useful in patients with BN. They may contain occlusive material (petrolatum or lanolin) and humectants (glycerin, propylene glycol and proteins). Alpha-hydroxy acids and urea may also be added to increase the water-binding capacity of the NP.
Several lacquers are commercially available to restructure nails affected by fragility. These products are known as nail hardeners, nail strengtheners, and fortifying nail builders, and may contain silicon. A new water-soluble nail strengthener specially formulated with a combination of active ingredients (silanediol salicylate and Pistacia lentiscus gum) that increase the quantity and quality of silicon and keratin in the nails. It contains cationic hyaluronic acid that adheres to the surface and deeply moisturizes the nails and cuticles. This combination of ingredients (patent pending) helps the natural process of nail growth. The safety and efficacy are supported by a 6-month clinical study .
A recent study observed that hydroxypropyl chitosan (HPCH) nail lacquer when applied on the nails is useful to protect them against physical injuries, improving the nail structure . The authors correlate the efficacy of HPCH to the high affinity with keratin that is secondary to water solubility without pH correction.
A second lacquer composed of 16% polyureaurethane could be used in BN to create a flexible waterproof barrier to environmental hazards . The once daily application of both lacquers is recommended.
In a randomized controlled pilot study, the efficacy of topical cyclosporine emulsion (CsAE) versus emulsion (vehicle) alone have been compared. CsAE and also emulsion alone appeared to improve signs of brittle nails. Limitations of this study were the small sample size and the method for detection of efficacy .
These nail lacquers could increase the cosmetic outcomes of BN, but further data are necessary to prove their true efficacy .
In recalcitrant fragility, nail wrapping limited to the distal portion of the nail may afford protection and camouflage. The procedure of nail wrapping consists of the application of layers of fibrous substances made of tissue paper, silk, linen, plastic film, or fiberglass on the distal edge of the NP to strengthen or repair its free edge. This same method is performed in artificial nails and sculptured nails and can considerably improve BN cosmetically. However, artificial nails could themselves be responsible for fragility because of the materials and procedures used to apply them [45, 46].
Good advice is to wear cotton gloves under vinyl gloves for wet work and heavy cotton gloves for dry work.
BN are a common complaint of patients presenting to a dermatologist. Before making a diagnosis of idiopathic BN, secondary causes that might be responsible for NB should be investigated and excluded. Optimal management requires the treatment of the primary cause of BN when present, protective measures and bio-mineral supplementation. In addition, several products could be considered to reduce the physical and psychological impacts of this common problem, although double-blind, randomized controlled studies of such products are still lacking.
ISDIN provided funding to enable Bianca M. Piraccini to write to the article, no other funding was received for this study. The Rapid Service Fee was funded by the authors.
All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.
Marco A. Chessa, Matilde Iorizzo, Bertrand Richert, Jose L. López Estebaranz, Dimitrios Rigopoulos, Antonella Tosti, Aditya K. Gupta, Nilton Di Chiacchio, Nilton G. Di Chiacchio, Adam I. Rubin, Robert Baran, Shari R. Lipner, Ralph Daniel, Soumya Chiheb, Chander Grover, Michela Starace, Bianca M. Piraccini have nothing to disclose.
Compliance with Ethics Guidelines
This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors.
This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
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