What is yellow nail syndrome?
Yellow nail syndrome is a rare condition defined by a combination of three features. These are thickened, slow-growing yellow nails, swelling of the limbs due to lymphoedema, and chest problems, most commonly fluid around the lungs (pleural effusion), bronchiectasis or chronic sinusitis. Not every patient has all three, and the features may appear years apart.
The condition is believed to result from abnormal function of the lymphatic vessels, which normally drain fluid from tissues back into the bloodstream. It usually begins in middle age, although it can occur at any age.
Symptoms
Nails
Nails become yellow or greenish-yellow, thick, overly curved and very slow-growing. The cuticles may be lost and nails may lift off or shed. Usually all fingernails and toenails are affected.
Lymphoedema
Swelling, typically of both legs and ankles, which may be mild or marked.
Chest and sinuses
- Breathlessness from pleural effusion, often on both sides and recurring after drainage
- Chronic cough with sputum and repeated chest infections from bronchiectasis
- Persistent nasal blockage, discharge and facial pressure from chronic sinusitis
Causes and associations
The exact cause is not known. Most cases have no identifiable trigger. In some people the syndrome has been reported in association with cancers, autoimmune disease, thyroid disease or certain medicines, so these are looked for at diagnosis. A small number of familial cases exist, but the condition is generally not inherited. It is not contagious.
How yellow nail syndrome is diagnosed
The diagnosis is clinical: it is usually made when at least two of the three main features are present and other explanations have been excluded. Tests concentrate on assessing the chest and excluding other causes.
| Test | What it shows |
|---|---|
| Chest X-ray and CT | Pleural effusions, bronchiectasis and any underlying lung disease |
| Pleural fluid analysis | Typically a protein-rich fluid with lymphocytes, sometimes milky (chylous). Also excludes infection and cancer |
| Pleural fluid ADA, cultures and cytology | Exclusion of tuberculosis and malignancy |
| Sputum culture | Bacteria that need treatment in bronchiectasis |
| Sinus imaging | Chronic sinusitis |
| Lymphoscintigraphy | Abnormal lymphatic drainage in the limbs, in selected cases |
In India, a recurring lymphocytic pleural effusion is very often due to tuberculosis, and many patients with yellow nail syndrome receive anti-tuberculosis treatment before the diagnosis is recognised. Careful fluid testing, and sometimes pleural biopsy by thoracoscopy, helps avoid this. Heart failure, kidney disease, low protein levels and fungal nail infection are also excluded.
Treatment
There is no cure, but each feature can be treated. Care is shared with dermatology, ENT and, where needed, thoracic surgery.
Pleural effusion
Small effusions may only need observation. Larger effusions causing breathlessness are drained. When fluid keeps returning, options from pleural disease management include pleurodesis to seal the pleural space, an indwelling pleural catheter that allows drainage at home, or surgical procedures such as decortication or pleurectomy, which can be performed through thoracoscopy or by thoracic surgeons.
Bronchiectasis and sinusitis
- Daily airway clearance physiotherapy
- Antibiotics for infections, and long-term macrolide treatment for frequent exacerbations
- Influenza and pneumococcal vaccination
- Nasal saline rinses and nasal steroids, with ENT review
Nails and lymphoedema
Oral vitamin E and antifungal drugs of the triazole class have been reported to improve nail appearance in some patients, although evidence is limited. Lymphoedema is managed with compression garments, skin care, exercise and lymphatic drainage massage.
Outlook and follow-up
Yellow nail syndrome is a long-term condition, but most people live with it for many years. Nail changes improve spontaneously in a proportion of patients. Regular follow-up monitors the pleural fluid, bronchiectasis and any associated condition.
Day-to-day measures help considerably: keeping the skin of swollen legs clean and moisturised to prevent infection, wearing compression garments as advised, staying active, and following the airway clearance routine. Any new symptom, such as increasing breathlessness or a change in sputum, should prompt an earlier review rather than waiting for the next scheduled appointment.
When to seek urgent care
Seek urgent medical help for rapidly increasing breathlessness, breathlessness at rest, chest pain, high fever with worsening cough, coughing up blood, or a red, hot and painful swollen leg, which may indicate cellulitis or a blood clot.
Frequently asked questions
Is yellow nail syndrome a fungal infection?
No. The nail changes look similar to fungal infection, but they are caused by the syndrome itself. Nail tests can exclude fungal infection.
Why does the fluid around my lungs keep coming back?
Abnormal lymphatic drainage means fluid continues to collect. If it recurs often, a procedure to seal the pleural space or an indwelling catheter for home drainage can control it.
Do I need treatment for tuberculosis?
Only if tuberculosis is confirmed or strongly suspected. Pleural fluid tests, and sometimes a pleural biopsy, help determine whether tuberculosis is present.
Will my nails return to normal?
Nail changes improve in some people over time, either on their own or with treatment such as vitamin E or antifungal tablets, but improvement is not guaranteed.
Is yellow nail syndrome linked to cancer?
Most people with yellow nail syndrome do not have cancer. Because an association has been reported in a minority, age-appropriate checks for cancer are part of the assessment.
Related conditions and procedures
Consult Dr. Gogineni Ratnakara Rao
Apollo Hospitals, Financial District: Monday to Saturday, 8:30 AM to 5:00 PM. Anything in Lung Clinic, Chanda Nagar: Monday to Saturday (Thursday closed), 6:00 PM to 9:00 PM.