Nail disorders are common in the older age group and are due to several causes including fungal infections, trauma, biomechanical tasks, systemic disorders, drugs ingested and could also be idiopathic. Aging changes can be seen in the hair, nails and the skin. The colour of the nails may become darker, there could be longitudinal ridges and they become more brittle [1]. The hair becomes thinner, coarse and loses its colour due to reduced melanin. This aging changes is more pronounced in Caucasian skin where there is reduced levels of melanin [2]. The characteristic histological finding in the aged skin is the loss of collagen while wrinkling and pigment changes are the most salient cutaneous manifestations [3]. Nail disorders have been observed to occur in older age groups even amongst Africans [4]. Scalp and hair disorders are known to be common in this age group and are due to multiple causes including fungal infections [5]. Fungal skin infections are known to be prevalent among the elderly within the region [6]. This study aims to document the nail and hair disorders seen in those aged 60 years and above who were admitted into the wards of University of Port Harcourt Teaching Hospital, Alakahia and identify possible associations.

Study Area

The study took place in the University of Port Harcourt Teaching Hospital (UPTH). The hospital is a 700-bed tertiary hospital located in Port Harcourt, Rivers state, Nigeria. The hospital plays host to a variety of medical specialists and serves as a referral center for other health care facilities in the state and neighbouring states as well.

The Study Population

The study population included persons aged 60 years and above presenting to University of Port Teaching Hospital, Alakahia for medical attention who were admitted to the wards after presentation.

Sample and Sampling

A purposive cross-sectional sampling of 126 elderly patients that were admitted to the different wards of the hospital within a 3-month period was carried. Patients were examined for skin, hair and nail disorders.

Data Collection

A pro forma data collection sheet was used to collate bio data which included age, sex, marital status, level of education and occupation; physical examination of skin, hair and nails were recorded and other medical diagnoses were also noted via the hospital folders.

Data Analysis

The data collected and analysed using Microsoft Office Excel 2010. Tables were constructed for the presentation of the results to improve data visualization and comprehension.

Limitations

This study was an observational and diagnosis was mainly clinical.

Out of the 126 older adults examined 30.1% (38) had nail changes in either their toe nails or fingernails which consisted of 31.6% (12) females and 68.4 %(26) males, having the M: F ratio to be 2.2:1. Changes only in their lower limb digits were noted in 68.4% (26) of patients while 13.2 %(5) persons had nail changes only in their upper limb digits and 18.4. % (7) persons had nail changes seen both on their toes and fingers. 22.2% (28) had dystrophic toe nail changes characterized by brittleness, hyperkeratosis and ridging. There were in growing toe nails seen bilaterally involving the halluces in a female; 2.38% (3) had brownish colouration (melanonychia) of toe nails while 0.79% (1) person had leuconychia. The hallux was the toe commonly affected in this elderly population with 25% of cases involving just the unilateral or bilateral halluces. Dystrophic finger nail changes were seen in 6.34% (8) with onychomycosis of the index and thumb finger as diagnosis in a male patient, 2.38% (3) had melanonychia and 0.79% (1) had leuconychia. The index finger was the finger commonly affected with 25% (2) of cases being the only digit affected (Figure 1).

The commonest chronic medical conditions seen were hypertension in 50 % (19), diabetes 36.8 % (14), malignancy 15.8% (6) and stroke 13.2% (5). This is not significantly different from those without nail changes. The commonest profession associated with nail changes in this group which were is farming 23.7 % (9) and teaching 10.5% (4). This finding was not significantly different from those without nail changes. Previous tobacco consumption was noted in 7.9 % (3) of those with nail changes and there were all males. The use of skin lightening was also noted in 7.9 % (3) of those with nail changes. 

Figure 1: Xerosis with Brownish Left Hallux

Figure 2: Frontal Androgenic Alopecia

Figure 3: Discolouration of Right Index

Table 1: Age Categories of Those with Nail Dystrophy

Table 2: Skin Manifestations in Those with Nail and Hair Changes

They were two females and a male. Hair disorders were seen in 4.8 % (6) of patients. Alopecia was the only complaint, with different types of alopecia noted in the population. Traction alopecia was seen in 1.6 % (2), patchy alopecia in 1.6 % (2) and 1.6 % (2) had androgenic alopecia (male pattern baldness) while one with androgenic had brownish hair discolouration. Those with patchy hair loss and traction alopecia were all females. Dyed hair was seen in 7.1 % (9) of the older persons with the M: F of 2:1 (Table 1) (Figure 2).

Skin manifestations were noted in those with 57.9% (22) of those with nail changes and 66% (4) of those with hair changes. The commonest skin manifestation seen with those with nail changes was xerosis with 36.8 % (14) followed by hyper pigmentation 21.1% (8) and fungal skin infections in 7.9 % (3). Post bleaching syndrome(PBS) was noted in only one of the females making use of skin lightening (bleaching) creams with dystrophic nails but the two females with traction alopecia without dystrophic nails also had PBS (exogenous onchronosis) as noted in Table 2 (Figure 3).

Dystrophic nail changes in older adults are common and they include a variety of descriptions as seen in our study [7,8]. In a study done in similar age group showed common nail changes to include pale, dull, opaque and lusterless nails; brittle nails, decreased lunula visibility and onychorrhexis with a higher prevalence. This difference may be attributed to the varying geographical area, population and the variation in characteristic findings.8 The study showed a higher male prevalence which is similar to other studies. El-Domyati et al. had an M: F of 1.6: 1 Snidgha et al had 3:2 and Yogender et al. was 2.45:1.8-10 This study showed more toe nails involvement, however the predominance of which of the limb digits most involved depends on the type of disease. In onychomycosis it commonly affects the toenails while in psoriasis it commonly affects the fingernails [11-13]. The hallux is known to be commonly affected by dystrophy either resulting from infections or trauma in the study as also reported by Leeyaphan et al. (2018) [10,11,14]. Chronic medical conditions such as diabetes and hypertension have also been noted to be associated with nail dystrophies as seen in other studies [8,10,11]. Agricultural workers such as farmers have been noted to be the most predisposed to have dystrophic nail changes as seen in this study. This finding is similar to studies done by El-Domyati et al., Snidgha et al., Yogender et al., Araiza-Santibáñez et al. and Maluki and Al-Hulli [8-11,14-15]. Housewives and beauty care workers are noted to have high risk of developing dystrophic nail changes but this study didn’t reflect which is likely due to the fact this is an older population [10,16]. Tobacco use has been associated with the development of dystrophic nails [17,18]. Harlequin nail has been proposed as the name given to the clinical observation of a distinct line of demarcation between the distal pigmented nail and the newly emerging proximal non-pigmented nail proposed by Verghese et al. which has been commonly noticed amongst those who suddenly stop smoking due to an intercurrent illness such as stroke [17]. Skin lightening creams (SLCs) have been implicated in discolouration of nails as reported in studies in older adults with hydroquinone being the most implicated substance [19, 20]. It is also noted to cause exogenous onchronosis which is one of the major manifestations of the post bleaching syndrome [21]. Alopecia is a common hair disorder among different age groups including the elderly with varying causes as seen in this study [5,22]. It is comparable to the study done by Anyalowo in 2017 however there was higher male preponderance unlike this study which was female dominated. This may likely due to the fact that the study done by Anyalowo was a retrospective study which cut across different age groups [5]. Skin diseases such as lichen planus, psoriasis and fungal skin infections commonly have nail disorders however it was only fungal skin infections as noted in Table 2 that were seen in this age group [23]. Fungal skin infections and onychomycosis are common dermatological manifestations in the elderly [3,6]. Bullous pemphigoid which is a rare autoimmune disease but more common in the elderly has been noted to be associated with different nail changes as also seen in our study [24,25]. Xerosis which is a common skin sign in the elderly that is due to reduced oil content of the skin due to aging was the commonest finding in this study and has be seen in others as well [3,6,26]. Hyperpigmentation is also a common skin manifestation in the elderly as seen in this study [3,6]. It is interesting to note that aesthetic practices occurs even in the elderly and some can cause physical distortion of the hair, nails and even the skin as seen in this study where there cases of brownish discolouration of nails, traction alopecia and exogenous ochronosis which has been noted in another study of Sub Saharan Africans, although the study focused on women in a younger age group [27].

There is a variety of hair and nail disorders in the elderly. Fungal infections can negatively impact the hair, nails and the skin.

1. Dugdale, D. “Aging changes in nails.” MedlinePlus, Accessed 18 December 2021. https://medlineplus.gov/ency/imagepages/8671.htm

2. Basaraba, S. “How aging affects your hair.” Verywell Health, Accessed 18 December 2021. https://www.verywellhealth.com/how-aging-affects-your-hair-2223752

3. Stella, A.E. “Biological and social challenges of the aging skin in older Africans.” Asian Journal of Research in Dermatological Science, vol. 4, no. 2, 2021, pp. 7–20.

4. Jassi, R. et al. “Clinical profile of nail apparatus abnormalities in dermatology patients.” Egyptian Journal of Dermatology and Venerology, vol. 36, 2016, pp. 51–56.

5. Ayanlowo, O.O. “Scalp and hair disorders at the dermatology outpatient clinic of a tertiary hospital.” Port Harcourt Medical Journal, vol. 11, 2017, pp. 127–133.

6. Amadi, E.S. et al. “The prevalence and pattern of dermatological disorders.” Nigerian Journal of Medicine, vol. 26, no. 1, 2017, pp. 23–28.

7. Abdullah, L.and O. Abbas. “Common nail changes and disorders in older people: diagnosis and management.” Canadian Family Physician, vol. 57, no. 2, 2011, pp. 173–181.

8. El-Domyati, M. et al. “Nail changes and disorders in elderly Egyptians.” Journal of Cosmetic Dermatology, vol. 13, no. 4, December 2014, pp. 269–276.

9. Snigdha, J. et al. “A study on the pattern of nail changes and nail disorders in geriatric patients in a tertiary care hospital in a rural setting.” Scholars Journal of Applied Medical Sciences, vol. 4, no. 12C, 2016, pp. 4394–4400.

10. Yogender, K. et al. “A study on pattern of nail changes in geriatric population.” Journal of Medical Science and Clinical Research, vol. 5, no. 8, August 2017.

11. Araiza-Santibáñez, J. et al. “Onychomycosis in the elderly: A Two-year retrospective study of 138 cases.” Revista Médica del Hospital General de México, vol. 79, no. 1, 2016, pp. 5–10.

12. Contour Dermatology. “Nail dystrophy and disease.” https://contourderm.com/nail-dystrophy-and-disease/ Accessed 19 December 2021.

13. Marks, J.G.and J.J. Miller. “Nail dystrophy.” Lookingbill and Marks’ Principles of Dermatology, 5th ed., 2013. Accessed 19 December 2021 https://www.sciencedirect.com/topics/medicine-and-dentistry/nail-dystrophy.

14. Leeyaphan, C. et al. “Clinical and laboratory findings in trauma-induced nail dystrophy versus onychomycosis.” Siriraj Medical Journal, vol. 70, 2018, pp. 490–495.

15. Maluki, A.and A. Al-Hulli. “The frequency of nail changes and disorders in Iraqi people above 50 years old.” Journal of Cosmetics, Dermatological Sciences and Applications, vol. 6, 2016, pp. 124–132.

16. Archibong, J. et al. “Occupational skin disorders in a subset of Nigerian hairdressers.” Pan African Medical Journal, vol. 31, 2018, p. 100.

17. Verghese, A. et al. “The harlequin nail: A marker for smoking cessation.” Chest, vol. 97, no. 1, January 1990, pp. 236–238.

18. Al-Delaimy, W.K. et al. “Toenail nicotine levels as a biomarker of tobacco smoke exposure.” Cancer Epidemiology, Biomarkers & Prevention, vol. 11, no. 11, November 2002, pp. 1400–1404.

19. Glazer, A. et al. “Nail discoloration after use of hydroquinone.” JAAD Case Reports, vol. 2, no. 1, February 2016, pp. 57–58. https://doi.org/10.1016/j.jdcr.2015.12.001.

20. Mann, R.J.and R.R. Harmann. “Nail staining due to hydroquinone skin lightening creams.” British Journal of Dermatology, vol. 108, 1983, pp. 363–365.

21. Charlín, R. et al. “Hydroquinone-induced exogenous ochronosis: A report of four cases and usefulness of dermoscopy.” 

22. Maddy, A.J.and A. Tosti. “Hair and nail diseases in the mature patient.” Clinics in Dermatology, vol. 36, no. 2, 2018, pp. 159–166.

23. Tosti, A.and C. Piraccini. “Biology of nails and nail disorders.” Fitzpatrick’s Dermatology in General Medicine, 7th ed., edited by K. Wolff et al., McGraw-Hill, 2008, pp. 778–794.

24. Tosti, A. et al. “Nail involvement in autoimmune bullous disorders.” Dermatologic Clinics, vol. 29, no. 3, July 2011, pp. 511–513.

25. Gopal, V. et al. “Nail changes in autoimmune blistering disorders: A case-control study.” Indian Journal of Dermatology, Venereology and Leprology, vol. 84, no. 3, May–June 2018, p. 373.

26. Health Hub. “Skin problems in the elderly.” https://www.healthhub.sg/a-z/diseases-and-conditions/428/skin%20_problems_in_the_elderlyi_nsc Accessed 19 December 2021.

27. Ly, F. et al. “Aesthetic problems associated with the cosmetic use of bleaching products.” International Journal of Dermatology, vol. 46, suppl. 1, October 2007, pp. 15–17.