What are the other Names for this Condition? (Also known as/Synonyms)

• Onychogryposis
• Ram's Horn Nails

What is Onychogryphosis? (Definition/Background Information)

• Onychogryphosis is a relatively common nail disorder in which the nails grow abnormally, and are yellow, thick, and unusually twisted. Hence, the disorder is also known as Ram's Horn Nails
• Onychogryphosis commonly involves the toenails and may develop from skin diseases, injury, poorly-controlled diabetes, fungal infection, or even due to senility (old age)
• The treatment for Onychogryphosis may involve both conservative (home and personal care) measures and medical procedures. With prompt and adequate treatment, the prognosis can be good

Who gets Onychogryphosis? (Age and Sex Distribution)

• Onychogryphosis may be observed in individuals of a wide age range, including in newborn children. However, most of the cases are observed into old age
• Both males and females are affected
• Worldwide, there is no racial or ethnic preference observed

What are the Risk Factors for Onychogryphosis? (Predisposing Factors)

The risk factors for Onychogryphosis include:

• Older adults, particularly those with senile dementia
• Poor sense of hygiene and personal habits (self-neglect)
• Not cutting one’s nails for extended durations
• Fungal nail infection
• Trauma to the foot - due to an injury or from wearing tight footwear
• Hammer toe and bunion
• Skin conditions that include:
  • Gout
  • Ichthyosis
  • Pemphigus
  • Psoriasis
  • Tertiary syphilis
• Peripheral vascular disease
• Genodermatoses - rare genetic conditions that present skin manifestations
• Tuberous sclerosis complex (TSC)
• In rare cases, a positive family history of the condition

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Onychogryphosis? (Etiology)

Onychogryphosis may be caused from congenital factors (rarely) or acquired factors (commonly).

• The most common causes are poor nail care, old age (including mental health issues), and injury
• It can also be the result of an underlying medical condition such as psoriasis, ichthyosis, nail fungus, or peripheral arterial disease
• Genetic conditions that may cause Onychogryphosis include tuberous sclerosis complex (TSC) or some other genodermatoses

Onychogryphosis is a hypertrophic condition involving the nail plate/matrix. In hypertrophy, there is an abnormal growth of the cells (in size and numbers). Often, the growth is uneven, resulting in one side of the nail growing faster, while the other side is relatively constrained. This results in severely deformed nails.

What are the Signs and Symptoms of Onychogryphosis?

The signs and symptoms of Onychogryphosis may include:

• Presence of rough and long (or stubby) nails that are irregular and distorted 
• Unevenly thickened and twisted nails that are yellow-brown in color
• Irregularly surfaced nail bed with cross striations
• Generally, the toes are affected more than the fingers
• The nails may not grow along the line of the toe or finger but can be bent at any angle
• In many cases, only a few to some digits (fingers and toes) may be involved
• Rarely, all 20 digits may be affected because the underlying cause may be a genetic condition
• The condition can cause ingrown toenails and infection

Additional signs and symptoms of the underlying condition, if any present, may be noted.

How is Onychogryphosis Diagnosed?

A diagnosis of Onychogryphosis may involve the following exams and procedures:

• Physical examination of the individual and medical history evaluation; generally, a visual examination may help in diagnosing Onychogryphosis
• However, further investigative tests and procedures may be needed to detect the underlying causative condition. These may include laboratory tests, imaging scans, genetic studies, and a tissue biopsy, as requested by the healthcare expert

A differential diagnosis may be necessary to eliminate other conditions that present similar signs and symptoms such as:

• Congenital malalignment of toenails
• Onychomycosis
• Pachyonychia congenita

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Onychogryphosis?

Onychogryphosis is a progressive condition, which gets worse with time in the absence of suitable intervention. The possible complications include:

• Emotional stress due to cosmetic issues
• Social self-isolation
• Superimposed bacterial and fungal skin infections
• Paronychia - inflammation of surrounding tissues
• Gangrene formation in the affected digit
• Interference with daily activities
• Unable to participate in sports and other physical activities
• Recurrence of the condition following treatment
• Treatment complications

Complications from the underlying condition, if any present, may be noted.

How is Onychogryphosis Treated?

The treatment measures available for Onychogryphosis depend on the severity of the condition and the underlying cause. The treatments may include:

• Treating the underlying cause is a very important consideration
• Conservative measures (for mild cases):
  • Good personal hygiene and nail care
  • Clipping overgrown nails
  • Abrasion of irregular nails
  • Manicure
  • Use of proper footwear
  • Protect nail from further injury till it heals, especially if trauma is the cause

Non-invasive and invasive procedures employed may include:

• Cryotherapy
• Medical nail avulsion
• Surgical nail removal techniques:
  • Scalpel excision
  • Cutting electrosurgery
  • Laser surgery using CO2 laser
• Chemical nail removal through:
  • Chemical cautery
  • Electrosurgery
  • Laser ablation
• Nail matrix removal through V-Y advancement flap (Zadik technique)

Regular follow up visits with the healthcare provider is important and recommended.

How can Onychogryphosis be Prevented?

In many cases, Onychogryphosis may be prevented by considering the following measures:

• Taking good care of elderly adults, especially those who are infirm or of poor mental health
• Maintaining good hygiene and personal care habits
• Keeping one’s nails short and trim
• Treating any underlying skin condition/infection or vascular disease early and appropriately
• If there is a family history of the condition, then genetic counseling will help assess risks before planning for a child

What is the Prognosis of Onychogryphosis? (Outcomes/Resolutions)

The prognosis of Onychogryphosis is generally good with adequate treatment. However, the condition may recur if the underlying cause is not addressed suitably.

Additional and Relevant Useful Information for Onychogryphosis:

The following DoveMed website link is a useful resource for additional information:

https://www.dovemed.com/healthy-living/skin-disorders/