To the Editor:

Nail changes are important findings of physical examination,which may be the only initial sign of a serious systemic illness.Skin and nail abnormalities are frequently associated with chronic liver disease,however these findings are mostly overlooked due to ignoring hand examination.One of these unrecognized nail findings in liver disease is Terry's nail.We present a patient with decompensated cirrhosis and hepatocellular carcinoma who has a previously unnoticed nail discoloration which eventually diagnosed as Terry's nail.The patient was a 65-year-old woman with a diagnosis of cryptogenic cirrhosis.She was referred to our hospital for evaluation of recent decompensation,and a thorough work-up revealed 2 lesions compatible with hepatocellular carcinoma.A nail discoloration previously overlooked was noted during the physical examination (Fig.).The proximal parts of herfingernails were white with a loss of lunula and a zone of normal pink at the distal edge of the nails,which extends a few milimeters to the proximal in the middle.A diagnosis of Terry's nail was made.

Fig.Terry's nails associated with cirrhosis.Note the white discoloration of proximal nails and loss of lunula.

Terry's nail is a non-specific finding associated with many clinical conditions including chronic liver and kidney diseases,congestive heart failure,diabetes mellitus and aging.[1]A study[2]suggested that decreased vascular supply to nail bed is responsible for the discoloration but tissue biopsies showed that nail abnormality is due to distal telangiectasia.This nail abnormality was first described in 1954 by Richard Terry,[3]who found that in 82 of 100 cirrhotic patients alcoholic liver disease was the most common etiology.Subsequent reports defined that Terry's nail was common in liver cirrhosis,however Salem et al[4]reported no patients with Terry's nail in their cohort.They explained this finding by inclusion of the insufficient number of patients with alcoholic cirrhosis and hepatocellular carcinoma.

Our patient was considered unsuitable for other therapies of hepatocellular carcinoma and listed for orthotopic liver transplantation.It is evident that hand examination and nail findings can give important clues in the management of patients with liver disease.

Bulent Baran,Ozlem Mutluay Soyer and Cetin Karaca

Department of Gastroenterohepatology,

Istanbul Faculty of Medicine,

Istanbul University,Capa 34390,

Fatih,Istanbul,Turkey

Tel:00902124142000;

Fax:00902126319743;

Email:cetinkaraca@yahoo.com

1 Nia AM,Ederer S,Dahlem KM,Gassanov N,Er F.Terry's nails:a window to systemic diseases.Am J Med 2011;124:602-604.

2 Holzberg M,Walker HK.Terry's nails:revised definition and new correlations.Lancet 1984;1:896-899.

3 Terry R.White nails in hepatic cirrhosis.Lancet 1954;266:757-759.

4 Salem A,Gamil H,Hamed M,Galal S.Nail changes in patients with liver disease.J Eur Acad Dermatol Venereol 2010;24:649-654.