Carpal tunnel syndrome and associated nail changes: Review and examples from the author's practice

J Am Acad Dermatol. 2020 Dec;83(6):1724-1729. doi: 10.1016/j.jaad.2020.03.023. Epub 2020 Mar 19.


Carpal tunnel syndrome (CTS) is commonly seen by general practitioners and often presents with neurologic symptoms of nocturnal pain and paresthesia along the median nerve distribution. Approximately 20% of patients also present with cutaneous findings (ulcerations, blistering, sclerodactyly, nail dystrophy) characterizing a severe form called necrotic CTS. Necrotic CTS can also be associated with bone changes (acro-osteolysis). In the author's practice, combined nail and skin findings are not an uncommon presentation of CTS, although this form remains overlooked and underreported in the dermatological textbooks and studies. This manuscript aims to review the literature on CTS cases, with a specific focus on using associated nail findings as diagnostic clues. The literature review along with a few additional recent cases from the author's practice demonstrate that CTS is frequently accompanied by a variety of nail changes including koilonychia, longitudinal fissuring, Beau's lines, onychomadesis, melanonychia, nail thickening, hyperkeratosis, and ischemic ulcerations with paronychia. Furthermore, when these changes are limited to the second and third fingernails, they should prompt the diagnosis of CTS. Once suspected, diagnostic evaluation is not difficult and surgical management can resolve cutaneous findings and prevent irreversible changes such as acro-osteolysis.

Keywords: acro-osteolysis; carpal tunnel syndrome; diagnostic clue; index fingernail; middle fingernail; nail changes; nail dystrophy; surgical decompression; topical nitroglycerin.

Publication types

  • Review

MeSH terms

  • Administration, Topical
  • Carpal Tunnel Syndrome / complications*
  • Carpal Tunnel Syndrome / diagnosis
  • Carpal Tunnel Syndrome / therapy
  • Decompression, Surgical
  • Fingers / innervation
  • Glucocorticoids / administration & dosage
  • Humans
  • Injections, Intralesional
  • Median Nerve / drug effects
  • Median Nerve / physiopathology
  • Nails / drug effects
  • Nails / innervation
  • Nails / pathology
  • Nails, Malformed / diagnosis*
  • Nails, Malformed / etiology
  • Nails, Malformed / pathology
  • Nails, Malformed / therapy
  • Necrosis
  • Nitroglycerin / administration & dosage
  • Severity of Illness Index
  • Splints
  • Treatment Outcome


  • Glucocorticoids
  • Nitroglycerin