What are the causes of koilonychia in picture the black color is mehnd

20260520_171932(1).jpg

What are the causes of koilonychia in picture the black color is mehndi bit nails are becoming flat

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koilonychia causes etiology

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Looking at the image you shared, the nails are clearly flat/concave (spoon-shaped) — this is classic koilonychia. The dark color is from mehndi (henna) as you mentioned, not a pathological change. Here is a comprehensive breakdown:

Koilonychia (Spoon Nails) — Causes & Overview

What it is: The nail plate becomes thin, flat, and eventually develops a concave (scooped-out) shape where the edges curve upward — like a spoon. Your image shows this clearly across multiple nails.

Textbook reference image of koilonychia (spooning):

Causes

1. Iron Deficiency (Most common systemic cause)

Moderate iron deficiency first causes fragile, longitudinally ridged, brittle nails
As deficiency progresses → nail plate thins, flattens, then becomes concave = koilonychia
The index and middle fingernails are usually most severely affected
Associated features: pallor, fatigue, glossitis (smooth tongue), angular stomatitis
Even after starting iron replacement, koilonychia resolves slowly
Plummer-Vinson syndrome: iron deficiency + dysphagia + koilonychia + glossitis (seen in middle-aged women)
Fitzpatrick's Dermatology, p. 2253 | Goldman-Cecil Medicine

2. Physiologic (Normal variant)

Common in young children (ages 1–4), especially toes 2–4
Resolves spontaneously — not pathological
Dermatology 2-Volume Set 5e

3. Occupational / Chemical exposure

Repeated contact with petroleum products, solvents, detergents, or alkalis damages the nail plate
Common in manual laborers, housewives with prolonged water/detergent exposure

4. Inflammatory skin diseases

Lichen planus — often with other nail changes (trachyonychia — rough, sandpaper nails)
Psoriasis (less common for koilonychia specifically)

5. Nutritional deficiencies

Iron deficiency is the classic one, but severe malnutrition can also cause it

6. Hereditary/Idiopathic

Rare familial forms exist (autosomal dominant)

What to Do

Given the clinical picture, the most important step is to check for iron deficiency anemia:

Test	What to check
CBC	Hemoglobin, MCV (low in iron deficiency)
Serum ferritin	Most sensitive marker for iron stores
Serum iron + TIBC	Low iron, high TIBC = iron deficiency
Transferrin saturation	Low (<16%)

Treatment: If iron deficiency confirmed → oral iron supplementation (e.g., ferrous sulfate). Nail changes improve slowly over weeks to months after treatment begins.

Bottom line: In an adult with koilonychia affecting multiple nails like in your photo, iron deficiency anemia is the most likely cause and should be investigated with a simple blood test. The black color on the skin and nails is just mehndi/henna and is not a concern.

Find clinical images of koilonychia in different severities

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koilonychia spoon nails clinical appearance severity

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Here are clinical images of koilonychia across different severities, with context for each:

Koilonychia — Clinical Images by Severity

🟡 Mild — Early Flattening (Loss of Normal Convexity)

Mild koilonychia — flat nails, early stage

What to see: The nails have lost their normal dome-shaped convexity and appear flat. Pale nail plates suggest underlying hypochromic state (iron deficiency). The lateral edges are starting to evert upward. Skin and cuticles otherwise intact.

🟠 Moderate — Concave Spooning, Macro Close-up

Moderate koilonychia — clear concave spoon shape, DermNet

What to see: Classic moderate koilonychia from DermNet. The nail plate is thin with a pronounced central depression. Lateral and distal edges curl upward. Longitudinal ridging is visible. The nail surface has mild translucency. At this stage, iron deficiency is typically well established.

"Spoon nails are thin and concave, with the edges everted so that if a drop of water were placed on the nail, it would not run off." — Andrews' Diseases of the Skin

🔴 Severe — Advanced Koilonychia with Chromonychia (Both Hands, Inpatient)

Severe koilonychia — both hands, hospitalized patient with brownish discoloration

What to see: Severe koilonychia affecting all fingernails bilaterally in a hospitalized patient (IV line visible). Nails are deeply concave, thin, and brittle with brownish-dark discoloration (chromonychia). This is consistent with advanced, chronic iron deficiency anemia (Plummer-Vinson syndrome pattern). The skin also shows pallor.

🔄 Before & After — Resolution After Treatment

Koilonychia resolving after treatment — three-panel comparison (A: active, B: resolving, C: resolved)

What to see:

Panel A — Active koilonychia: nails are flat with concave, spoon-shaped distal ends (red arrows)
Panel B — 8 months after treatment: concavity visibly reduced (yellow arrows), curvature normalizing
Panel C — 1 year post-treatment: nails have returned to normal convex contour (white arrows)

This illustrates that koilonychia resolves slowly even after the underlying cause is corrected — nails regenerate at ~3 mm/month.

Severity Summary

Severity	Nail Change	Likely Stage
Mild	Flat, loss of convexity, pale	Early iron depletion
Moderate	Clearly concave, ridged, edges everted	Established iron deficiency
Severe	Deep spooning, brittle, discolored	Chronic/advanced deficiency (Plummer-Vinson)
Resolving	Gradual return of convexity	Post iron supplementation

Sources: Andrews' Diseases of the Skin; Dermatology 2-Volume Set 5e; Fitzpatrick's Dermatology; DermNet NZ

Create a quick reference PDF on nail dystrophies and systemic causes

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mkdir -p /home/daytona/workspace/nail-dystrophies && ls /home/daytona/workspace/…

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~/nail-dystrophies/generate_pdf.py

#!/usr/bin/env python3
"""
Quick Reference PDF: Nail Dystrophies & Systemic Causes
Uses ReportLab for full layout control with images and tables.
"""

import requests
import os
from io import BytesIO
from PIL import Image as PILImage

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import cm, mm
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    Image, HRFlowable, KeepTogether, PageBreak
)
from reportlab.platypus.flowables import BalancedColumns
from reportlab.lib.colors import HexColor, white, black

OUTPUT = "/home/daytona/workspace/nail-dystrophies/Nail_Dystrophies_Quick_Reference.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
TEAL       = HexColor("#1A6B72")
TEAL_LIGHT = HexColor("#E8F4F5")
AMBER      = HexColor("#D97706")
AMBER_LITE = HexColor("#FEF3C7")
RED        = HexColor("#B91C1C")
RED_LITE   = HexColor("#FEE2E2")
PURPLE     = HexColor("#6D28D9")
PURPLE_LT  = HexColor("#EDE9FE")
GREY_DARK  = HexColor("#1F2937")
GREY_MID   = HexColor("#6B7280")
GREY_LIGHT = HexColor("#F3F4F6")
GREY_LINE  = HexColor("#D1D5DB")
WHITE      = white

W, H = A4
MARGIN = 1.8*cm

# ── Image downloader ────────────────────────────────────────────────────────
IMG_DIR = "/home/daytona/workspace/nail-dystrophies/imgs"
os.makedirs(IMG_DIR, exist_ok=True)

def fetch_img(url, fname, max_w_cm, max_h_cm):
    """Download image, resize to fit box, return ReportLab Image or None."""
    path = os.path.join(IMG_DIR, fname)
    if not os.path.exists(path):
        try:
            r = requests.get(url, timeout=15)
            r.raise_for_status()
            img = PILImage.open(BytesIO(r.content)).convert("RGB")
            img.save(path, "JPEG", quality=85)
        except Exception as e:
            print(f"  ✗ {fname}: {e}")
            return None
    try:
        img = PILImage.open(path)
        ow, oh = img.size
        mw = max_w_cm * cm
        mh = max_h_cm * cm
        scale = min(mw / ow, mh / oh)
        return Image(path, width=ow*scale, height=oh*scale)
    except Exception as e:
        print(f"  ✗ resize {fname}: {e}")
        return None

# ── Style sheet ─────────────────────────────────────────────────────────────
base = getSampleStyleSheet()

def style(name, parent="Normal", **kw):
    s = ParagraphStyle(name, parent=base[parent], **kw)
    return s

S = {
    "doc_title": style("DocTitle", "Title",
        fontSize=26, textColor=WHITE, leading=30,
        alignment=TA_CENTER, spaceAfter=4),
    "doc_sub":   style("DocSub", "Normal",
        fontSize=12, textColor=HexColor("#CBD5E1"),
        alignment=TA_CENTER, spaceAfter=2),
    "section":   style("Section", "Normal",
        fontSize=13, textColor=WHITE, leading=16,
        fontName="Helvetica-Bold", spaceBefore=2, spaceAfter=2),
    "heading2":  style("H2", "Normal",
        fontSize=11, textColor=TEAL, leading=14,
        fontName="Helvetica-Bold", spaceBefore=8, spaceAfter=3),
    "body":      style("Body", "Normal",
        fontSize=9, textColor=GREY_DARK, leading=13,
        spaceBefore=2, spaceAfter=2),
    "body_sm":   style("BodySm", "Normal",
        fontSize=8, textColor=GREY_DARK, leading=11),
    "caption":   style("Caption", "Normal",
        fontSize=7.5, textColor=GREY_MID, leading=10,
        alignment=TA_CENTER, spaceAfter=4),
    "bullet":    style("Bullet", "Normal",
        fontSize=8.5, textColor=GREY_DARK, leading=12,
        leftIndent=10, bulletIndent=0),
    "tag_teal":  style("TagTeal", "Normal",
        fontSize=7.5, textColor=TEAL, fontName="Helvetica-Bold"),
    "footnote":  style("Footnote", "Normal",
        fontSize=7, textColor=GREY_MID, leading=9,
        alignment=TA_CENTER),
}

def bullet(text):
    return Paragraph(f"• {text}", S["bullet"])

def sp(h=0.2):
    return Spacer(1, h*cm)

# ═══════════════════════════════════════════════════════════════════════════
# BUILD DOCUMENT
# ═══════════════════════════════════════════════════════════════════════════
story = []

# ── COVER BANNER ────────────────────────────────────────────────────────────
def cover_banner(canvas, doc):
    canvas.saveState()
    # Top banner
    canvas.setFillColor(TEAL)
    canvas.rect(0, H - 5.5*cm, W, 5.5*cm, fill=1, stroke=0)
    # Decorative accent strip
    canvas.setFillColor(AMBER)
    canvas.rect(0, H - 5.5*cm, W, 0.35*cm, fill=1, stroke=0)
    # Footer bar
    canvas.setFillColor(GREY_DARK)
    canvas.rect(0, 0, W, 1.1*cm, fill=1, stroke=0)
    canvas.setFillColor(WHITE)
    canvas.setFont("Helvetica", 7.5)
    canvas.drawCentredString(W/2, 0.4*cm,
        "Sources: Goldman-Cecil Medicine • Andrews' Diseases of the Skin • Fitzpatrick's Dermatology • "
        "Dermatology 2-Vol Set 5e • Harrison's Principles of Internal Medicine 22e")
    canvas.restoreState()

def later_pages(canvas, doc):
    canvas.saveState()
    # Thin top accent
    canvas.setFillColor(TEAL)
    canvas.rect(0, H - 0.6*cm, W, 0.6*cm, fill=1, stroke=0)
    canvas.setFillColor(WHITE)
    canvas.setFont("Helvetica-Bold", 7.5)
    canvas.drawString(MARGIN, H - 0.42*cm,
        "NAIL DYSTROPHIES & SYSTEMIC CAUSES  —  Quick Reference")
    canvas.drawRightString(W - MARGIN, H - 0.42*cm, f"Page {doc.page}")
    # Footer
    canvas.setFillColor(GREY_DARK)
    canvas.rect(0, 0, W, 0.9*cm, fill=1, stroke=0)
    canvas.setFillColor(WHITE)
    canvas.setFont("Helvetica", 7)
    canvas.drawCentredString(W/2, 0.32*cm,
        "Sources: Goldman-Cecil Medicine • Andrews' Diseases of the Skin • Fitzpatrick's Dermatology • "
        "Dermatology 2-Vol Set 5e • Harrison's Principles of Internal Medicine 22e")
    canvas.restoreState()

# ── Title block (placed on page 1 via offset) ───────────────────────────────
story.append(Spacer(1, 5.8*cm))  # push below cover banner
story.append(Paragraph("NAIL DYSTROPHIES", S["doc_title"]))
story.append(Paragraph("&amp; SYSTEMIC CAUSES", S["doc_title"]))
story.append(Paragraph("Quick Reference Guide for Clinicians", S["doc_sub"]))
story.append(Spacer(1, 0.5*cm))

# ── INTRO ───────────────────────────────────────────────────────────────────
intro = Table([[Paragraph(
    "<b>Nails as a diagnostic window:</b> Nail changes are among the most visible and accessible "
    "physical signs of systemic disease. A systematic examination of the nail plate, nail bed, "
    "lunula, and periungual tissue can point directly toward haematological, hepatic, renal, "
    "pulmonary, dermatological, and nutritional disorders. This guide provides a rapid visual "
    "and clinical reference for the major nail dystrophies encountered in practice.",
    S["body"])]],
    colWidths=[W - 2*MARGIN])
intro.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), TEAL_LIGHT),
    ("BOX",        (0,0), (-1,-1), 0.8, TEAL),
    ("LEFTPADDING",  (0,0), (-1,-1), 10),
    ("RIGHTPADDING", (0,0), (-1,-1), 10),
    ("TOPPADDING",   (0,0), (-1,-1), 8),
    ("BOTTOMPADDING",(0,0), (-1,-1), 8),
    ("ROUNDEDCORNERS", (0,0), (-1,-1), [4,4,4,4]),
]))
story.append(intro)
story.append(sp(0.4))

# ═══════════════════════════════════════════════════════════════════════════
# HELPER: section header bar
# ═══════════════════════════════════════════════════════════════════════════
def section_bar(title, color=TEAL):
    t = Table([[Paragraph(title, S["section"])]],
              colWidths=[W - 2*MARGIN])
    t.setStyle(TableStyle([
        ("BACKGROUND",   (0,0), (-1,-1), color),
        ("LEFTPADDING",  (0,0), (-1,-1), 10),
        ("RIGHTPADDING", (0,0), (-1,-1), 10),
        ("TOPPADDING",   (0,0), (-1,-1), 6),
        ("BOTTOMPADDING",(0,0), (-1,-1), 6),
    ]))
    return t

# ═══════════════════════════════════════════════════════════════════════════
# HELPER: two-column image + text card
# ═══════════════════════════════════════════════════════════════════════════
def img_card(url, fname, cap, title, body_paras, accent=TEAL, img_w=5.5, img_h=4.0):
    img = fetch_img(url, fname, img_w, img_h)
    title_p = Paragraph(title, style("CT", "Normal",
        fontSize=10, textColor=accent, fontName="Helvetica-Bold", spaceAfter=3))
    cap_p   = Paragraph(cap, S["caption"])
    left_content = [title_p] + body_paras
    left_cell  = left_content
    if img:
        right_cell = [img, cap_p]
    else:
        right_cell = [Paragraph("(image unavailable)", S["caption"])]
    t = Table([[left_cell, right_cell]],
              colWidths=[(W-2*MARGIN)*0.58, (W-2*MARGIN)*0.42])
    t.setStyle(TableStyle([
        ("VALIGN",       (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING",  (0,0), (0,-1), 0),
        ("RIGHTPADDING", (0,0), (0,-1), 8),
        ("LEFTPADDING",  (1,0), (1,-1), 4),
        ("RIGHTPADDING", (1,0), (1,-1), 0),
        ("TOPPADDING",   (0,0), (-1,-1), 0),
        ("BOTTOMPADDING",(0,0), (-1,-1), 4),
    ]))
    return t

# ═══════════════════════════════════════════════════════════════════════════
# SECTION 1 — KOILONYCHIA
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_bar("1  |  KOILONYCHIA  (Spoon Nails)"))
story.append(sp(0.3))

koi_body = [
    Paragraph("Nail plate becomes thin, flat, and centrally depressed with everted lateral and distal edges — classically spoon-shaped. A water drop placed on the nail will not run off.", S["body"]),
    sp(0.15),
    Paragraph("<b>Progression:</b> Normal → Brittle/ridged → Flat → Concave (spoon)", S["body"]),
    sp(0.2),
    Paragraph("<b>Systemic causes:</b>", S["body"]),
    bullet("<b>Iron deficiency anaemia</b> — most common systemic cause"),
    bullet("Plummer-Vinson syndrome (iron deficiency + dysphagia + glossitis)"),
    bullet("Haemochromatosis (faulty iron metabolism)"),
    bullet("Hypothyroidism / hyperthyroidism"),
    bullet("Lichen planus, psoriasis"),
    bullet("Raynaud syndrome / scleroderma"),
    bullet("Familial (autosomal dominant)"),
    bullet("Physiologic — toes of children aged 1–4 yrs (self-resolving)"),
    bullet("Occupational: chronic cold exposure, chemical damage"),
    sp(0.1),
    Paragraph("<b>Key exam tip:</b> Index and middle fingernails most severely involved. "
              "Resolves slowly even after iron replacement begins.", S["body_sm"]),
]
story.append(img_card(
    url="https://cdn.orris.care/cdss_images/pmc_clinical_VQA_f068a64e060f02ac65027cef8190c0bdbbd47fa6182f8dfc1b1f2fac848d31f0.jpg",
    fname="koilonychia_severe.jpg",
    cap="Severe koilonychia — both hands, iron deficiency anaemia\n(Source: PMC Clinical VQA)",
    title="KOILONYCHIA",
    body_paras=koi_body,
    accent=AMBER,
    img_w=6, img_h=4.5
))
story.append(sp(0.4))

# ═══════════════════════════════════════════════════════════════════════════
# SECTION 2 — NAIL CLUBBING
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_bar("2  |  NAIL CLUBBING  (Hippocratic Fingers)", color=RED))
story.append(sp(0.3))

club_body = [
    Paragraph("Bulbous enlargement of the distal phalanges with increased nail curvature. "
              "The Lovibond angle (nail-to-skin angle) becomes ≥ 180°. "
              "<b>Schamroth sign:</b> absence of the normal diamond window when opposing nails are placed together.", S["body"]),
    sp(0.15),
    Paragraph("<b>Causes by system:</b>", S["body"]),
    bullet("<b>Pulmonary (most common):</b> lung cancer, interstitial lung disease, bronchiectasis, cystic fibrosis, empyema"),
    bullet("<b>Cardiac:</b> cyanotic congenital heart disease, infective endocarditis"),
    bullet("<b>GI/Hepatic:</b> cirrhosis, inflammatory bowel disease, coeliac disease"),
    bullet("<b>Endocrine:</b> thyroid acropachy (Graves' disease)"),
    bullet("<b>Idiopathic / familial</b>"),
    sp(0.1),
    Paragraph("<b>Grade 0–4 scale:</b> 0 = normal; 1 = fluctuant nail bed; "
              "2 = obliterated Lovibond angle; 3 = drumstick digit; 4 = periosteal new bone.", S["body_sm"]),
]
story.append(img_card(
    url="https://cdn.orris.care/cdss_images/pmc_clinical_VQA_c1417ca016d4a73a335e093b49b2c1a5775f15cabbbe97cac2307c7d3231a750.jpg",
    fname="clubbing.jpg",
    cap="Classic digital clubbing — obliterated Lovibond angle\n(Source: PMC Clinical VQA)",
    title="CLUBBING",
    body_paras=club_body,
    accent=RED,
    img_w=6, img_h=4.5
))
story.append(sp(0.4))

# ═══════════════════════════════════════════════════════════════════════════
# SECTION 3 — BEAU LINES
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_bar("3  |  BEAU LINES  &amp;  ONYCHOMADESIS"))
story.append(sp(0.3))

beau_body = [
    Paragraph("Transverse grooves/depressions across the nail plate resulting from temporary "
              "interruption of nail matrix growth. In systemic disease, all nails are affected "
              "at the <b>same level</b>. Repeated lines indicate repeated insults (e.g. chemotherapy cycles). "
              "Timing can be calculated: nails grow ~3 mm/month.", S["body"]),
    sp(0.15),
    Paragraph("<b>Systemic causes:</b>", S["body"]),
    bullet("Severe febrile illness / sepsis"),
    bullet("Chemotherapy (especially taxanes, cyclophosphamide)"),
    bullet("Major surgery or trauma"),
    bullet("Malnutrition, zinc deficiency"),
    bullet("Kawasaki disease (children)"),
    bullet("COVID-19 (post-infectious)"),
    sp(0.1),
    Paragraph("<b>Onychomadesis</b> = complete nail shedding; represents severe matrix arrest. "
              "Same causes but more severe disruption.", S["body_sm"]),
]
story.append(img_card(
    url="https://cdn.orris.care/cdss_images/pmc_clinical_VQA_6d2475d51b662e3db2d3cc9ced04ad5416e9526d180b85bfd3b9bd2f049388eb.jpg",
    fname="beau_mees.jpg",
    cap="Beau lines + Mees' lines post-chemotherapy — multiple cycles visible\n(Source: PMC Clinical VQA)",
    title="BEAU LINES",
    body_paras=beau_body,
    accent=TEAL,
    img_w=6, img_h=4.5
))
story.append(sp(0.4))

# ═══════════════════════════════════════════════════════════════════════════
# PAGE BREAK
# ═══════════════════════════════════════════════════════════════════════════
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# SECTION 4 — TERRY'S NAILS / LEUKONYCHIA
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_bar("4  |  NAIL LEUKONYCHIA  —  Terry, Lindsay &amp; Muehrcke", color=PURPLE))
story.append(sp(0.3))

leuko_body = [
    Paragraph("<b>Terry's nails:</b> Ground-glass whitening of proximal nail bed; narrow (2–3 mm) "
              "distal pink/brown band. Lunula not visible.", S["body"]),
    bullet("Causes: liver cirrhosis, CCF, diabetes mellitus, hypoalbuminaemia, ageing"),
    sp(0.1),
    Paragraph("<b>Lindsay (half-and-half) nails:</b> Proximal white + distal red-brown; "
              "sharp demarcation at mid-nail.", S["body"]),
    bullet("Causes: <b>chronic kidney disease / uraemia</b> (classic), also liver disease"),
    sp(0.1),
    Paragraph("<b>Muehrcke's lines:</b> Paired white transverse bands on nail <i>bed</i> "
              "(not plate) — fade with pressure, do not move with nail growth.", S["body"]),
    bullet("Causes: hypoalbuminaemia (<2 g/dL), systemic chemotherapy, nephrotic syndrome"),
    sp(0.1),
    Paragraph("<b>Mees' lines:</b> Single white transverse bands on the nail <i>plate</i> "
              "(move with nail growth).", S["body"]),
    bullet("Causes: arsenic/thallium poisoning, renal failure, chemotherapy"),
    sp(0.1),
    Paragraph("<b>True leukonychia:</b> Opaque white nail plate — trauma, fungal, genetic.", S["body_sm"]),
]
story.append(img_card(
    url="https://cdn.orris.care/cdss_images/DermNetNZ_1760031552024_4bf2ecd3-bea0-4b0b-8db1-1faf59479ab3.jpg",
    fname="terry_nails.jpg",
    cap="Terry's nails — proximal whitening with distal pink band\n(Source: DermNet NZ)",
    title="LEUKONYCHIA PATTERNS",
    body_paras=leuko_body,
    accent=PURPLE,
    img_w=5.5, img_h=4.0
))
story.append(sp(0.3))

# Small Lindsay/half-and-half image inline
lindsay_img = fetch_img(
    "https://cdn.orris.care/cdss_images/DermNetNZ_1760033364276_9e2dff60-90fd-4516-9506-481207ae2e84.jpg",
    "lindsay_nails.jpg", 5.5, 3.5
)
if lindsay_img:
    cap2 = Paragraph("Lindsay (half-and-half) nails — CKD/uraemia (DermNet NZ)", S["caption"])
    t = Table([[lindsay_img, cap2]],
              colWidths=[(W-2*MARGIN)*0.42, (W-2*MARGIN)*0.58])
    t.setStyle(TableStyle([
        ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
        ("LEFTPADDING", (0,0), (-1,-1), 4),
    ]))
    story.append(t)
story.append(sp(0.4))

# ═══════════════════════════════════════════════════════════════════════════
# SECTION 5 — PSORIATIC NAILS
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_bar("5  |  PSORIATIC NAIL DISEASE", color=AMBER))
story.append(sp(0.3))

pso_body = [
    Paragraph("Nail involvement occurs in <b>~50% of psoriasis patients</b> and up to <b>80% of psoriatic "
              "arthritis</b> patients. Nail matrix disease vs nail bed disease produce distinct signs.", S["body"]),
    sp(0.15),
    Paragraph("<b>Matrix involvement:</b>", S["body"]),
    bullet("Pitting (most characteristic — shallow pinhole depressions)"),
    bullet("Leukonychia (white spots/patches)"),
    bullet("Onychorrhexis (longitudinal ridging)"),
    bullet("Beau lines"),
    sp(0.1),
    Paragraph("<b>Nail bed involvement:</b>", S["body"]),
    bullet("Onycholysis (distal plate separation)"),
    bullet("Oil-drop / salmon patch sign (translucent yellow-pink)"),
    bullet("Subungual hyperkeratosis"),
    bullet("Splinter haemorrhages"),
    sp(0.1),
    Paragraph("<b>Clinical significance:</b> Nail psoriasis predicts psoriatic arthritis. "
              "NAPSI score used to quantify severity. Treat with topical steroids, "
              "vitamin D analogues, biologics (TNF-α inhibitors).", S["body_sm"]),
]
story.append(img_card(
    url="https://cdn.orris.care/cdss_images/DermNetNZ_1760035388113_ba6309ba-8f4f-4489-9b44-8a3d4265bcc3.jpg",
    fname="psoriatic_nails.jpg",
    cap="Psoriatic nail dystrophy: onycholysis + subungual hyperkeratosis\n(Source: DermNet NZ)",
    title="PSORIATIC NAILS",
    body_paras=pso_body,
    accent=AMBER,
    img_w=6, img_h=4.5
))
story.append(sp(0.4))

# ═══════════════════════════════════════════════════════════════════════════
# SECTION 6 — LICHEN PLANUS
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_bar("6  |  NAIL LICHEN PLANUS"))
story.append(sp(0.3))

lp_body = [
    Paragraph("Lichenoid inflammation of the nail matrix produces characteristic changes. "
              "Can precede cutaneous or mucosal LP. Risk of permanent scarring (pterygium).", S["body"]),
    sp(0.15),
    bullet("Onychorrhexis (longitudinal ridging — hallmark)"),
    bullet("Thinning of nail plate (onychoatrophy)"),
    bullet("Fissuring and splitting"),
    bullet("Dorsal pterygium formation (scarring from matrix to plate)"),
    bullet("Onycholysis, subungual hyperkeratosis"),
    bullet("Twenty-nail dystrophy (trachyonychia) — all nails rough/sandpaper"),
    sp(0.1),
    Paragraph("<b>Associated conditions:</b> Discoid/systemic lupus, graft-vs-host disease, "
              "dyskeratosis congenita.", S["body"]),
    sp(0.1),
    Paragraph("<b>Treatment:</b> Topical / intralesional corticosteroids, systemic "
              "immunomodulators for severe disease.", S["body_sm"]),
]
story.append(img_card(
    url="https://cdn.orris.care/cdss_images/DermNetNZ_1760033664188_9a020e78-3208-4f1d-a630-a44d60f80a51.jpg",
    fname="lichen_planus_nails.jpg",
    cap="Nail lichen planus: longitudinal ridging, thinning, pterygium\n(Source: DermNet NZ)",
    title="LICHEN PLANUS",
    body_paras=lp_body,
    accent=TEAL,
    img_w=6, img_h=4.5
))
story.append(sp(0.4))

# ═══════════════════════════════════════════════════════════════════════════
# PAGE BREAK — Comprehensive reference table
# ═══════════════════════════════════════════════════════════════════════════
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# COMPREHENSIVE REFERENCE TABLE
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_bar("COMPREHENSIVE QUICK-REFERENCE TABLE — Nail Signs & Systemic Causes", color=GREY_DARK))
story.append(sp(0.3))

hdr_style = ParagraphStyle("TH", fontSize=8, textColor=WHITE,
                            fontName="Helvetica-Bold", leading=10)
cell_style = ParagraphStyle("TC", fontSize=7.5, textColor=GREY_DARK,
                             leading=10, spaceBefore=1, spaceAfter=1)
tag_style  = ParagraphStyle("Tag", fontSize=7, textColor=TEAL,
                             fontName="Helvetica-Bold", leading=9)

def th(t): return Paragraph(t, hdr_style)
def tc(t): return Paragraph(t, cell_style)
def tag(t, c=TEAL_LIGHT, tc_=None):
    ts = ParagraphStyle("Tg2", fontSize=7, textColor=c if tc_ is None else tc_,
                        fontName="Helvetica-Bold")
    return Paragraph(t, ts)

rows = [
    # header
    [th("Nail Sign"), th("Appearance"), th("Systemic Causes"), th("Investigation")],

    # Koilonychia
    [tc("Koilonychia\n(Spoon nails)"),
     tc("Concave nail plate;\nedges everted upward"),
     tc("• Iron deficiency anaemia\n• Plummer-Vinson syndrome\n• Haemochromatosis\n• Thyroid disorders\n• Raynaud / scleroderma"),
     tc("CBC, serum ferritin,\nserum iron, TIBC,\ntransferrin saturation")],

    # Clubbing
    [tc("Clubbing\n(Hippocratic nails)"),
     tc("Increased nail convexity;\nLovibond angle ≥180°;\nbulbous fingertips"),
     tc("• Lung cancer, IPF, bronchiectasis\n• Cyanotic heart disease\n• Liver cirrhosis, IBD\n• Thyroid acropachy"),
     tc("CXR, CT chest,\nechocardiogram,\nSpO2, LFTs")],

    # Beau lines
    [tc("Beau Lines"),
     tc("Transverse grooves;\nall nails at same level\nin systemic disease"),
     tc("• Febrile illness / sepsis\n• Chemotherapy\n• Malnutrition, zinc def.\n• COVID-19 (post-acute)"),
     tc("Date of insult from\nnail position (3 mm/mo);\nzinc, albumin")],

    # Terry's nails
    [tc("Terry's Nails"),
     tc("Proximal white;\nnarrow distal pink band;\nno lunula visible"),
     tc("• Liver cirrhosis\n• Congestive heart failure\n• Diabetes mellitus\n• Hypoalbuminaemia"),
     tc("LFTs, albumin,\nBNP/Echo,\nHbA1c")],

    # Lindsay (half-and-half)
    [tc("Lindsay Nails\n(Half-and-half)"),
     tc("Proximal white;\ndistal reddish-brown;\nsharp demarcation"),
     tc("• Chronic kidney disease\n• Uraemia / dialysis\n• Liver disease"),
     tc("eGFR, creatinine,\nurea, urinalysis")],

    # Muehrcke lines
    [tc("Muehrcke's Lines"),
     tc("Paired white transverse\nbands on nail bed;\nfade with pressure"),
     tc("• Hypoalbuminaemia (<2 g/dL)\n• Chemotherapy\n• Nephrotic syndrome"),
     tc("Serum albumin,\nurine protein,\n24h protein")],

    # Mees' lines
    [tc("Mees' Lines"),
     tc("Single white transverse\nbands on nail plate;\nmove with growth"),
     tc("• Arsenic / thallium poisoning\n• Renal failure\n• Chemotherapy"),
     tc("Heavy metals panel,\nrenal function,\nchemo history")],

    # Splinter haemorrhages
    [tc("Splinter\nHaemorrhages"),
     tc("Dark red-brown linear\nstreaks under nail;\ndistal = trauma;\nproximal = systemic"),
     tc("• Infective endocarditis\n• Vasculitis (SLE, RA)\n• Antiphospholipid syndrome\n• Trauma (distal)"),
     tc("Blood cultures, Echo,\nANA, ANCA,\naPL antibodies")],

    # Onycholysis
    [tc("Onycholysis"),
     tc("Nail plate separated\nfrom bed distally;\nwhite/yellow appearance"),
     tc("• Psoriasis (oil-drop sign)\n• Thyrotoxicosis\n• Drug-induced (taxanes)\n• Fungal infection"),
     tc("TFTs, KOH/culture,\nmedication review")],

    # Yellow nail syndrome
    [tc("Yellow Nail\nSyndrome"),
     tc("Thickened, curved,\nyellow-green nails;\nslow growth; no lunula"),
     tc("• Lymphoedema\n• Respiratory disease (pleural effusion, bronchiectasis)\n• Rarely malignancy"),
     tc("CXR, CT chest,\nlymphoscintigraphy")],

    # Pitting
    [tc("Nail Pitting"),
     tc("Small punched-out\ndepressions on\nnail surface"),
     tc("• Psoriasis (most common)\n• Alopecia areata\n• Eczema\n• Reactive arthritis"),
     tc("Clinical correlation;\njoint exam for PsA;\nskip biopsy for classic")],

    # Onychomycosis
    [tc("Onychomycosis"),
     tc("Thickened, discoloured,\nfriable nail; subungual\nhyperkeratosis;\nyellow-white-brown"),
     tc("• Tinea unguium (T. rubrum)\n• Candida (fingers > toes)\n• Non-dermatophyte mould"),
     tc("KOH microscopy,\nfungal culture,\nPCR/nail clipping\nbiopsy")],
]

col_w = [(W-2*MARGIN)*x for x in [0.18, 0.22, 0.37, 0.23]]
tbl = Table(rows, colWidths=col_w, repeatRows=1)

ts = TableStyle([
    # Header
    ("BACKGROUND",   (0,0), (-1,0), TEAL),
    ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
    ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,0), 8),
    ("TOPPADDING",   (0,0), (-1,0), 6),
    ("BOTTOMPADDING",(0,0), (-1,0), 6),
    # Alternating rows
    ("BACKGROUND",   (0,1), (-1,1),  TEAL_LIGHT),
    ("BACKGROUND",   (0,2), (-1,2),  WHITE),
    ("BACKGROUND",   (0,3), (-1,3),  TEAL_LIGHT),
    ("BACKGROUND",   (0,4), (-1,4),  WHITE),
    ("BACKGROUND",   (0,5), (-1,5),  TEAL_LIGHT),
    ("BACKGROUND",   (0,6), (-1,6),  WHITE),
    ("BACKGROUND",   (0,7), (-1,7),  TEAL_LIGHT),
    ("BACKGROUND",   (0,8), (-1,8),  WHITE),
    ("BACKGROUND",   (0,9), (-1,9),  TEAL_LIGHT),
    ("BACKGROUND",   (0,10),(-1,10), WHITE),
    ("BACKGROUND",   (0,11),(-1,11), TEAL_LIGHT),
    ("BACKGROUND",   (0,12),(-1,12), WHITE),
    # Grid
    ("GRID",         (0,0), (-1,-1), 0.4, GREY_LINE),
    ("LINEABOVE",    (0,0), (-1,0),  1.0, TEAL),
    ("LINEBELOW",    (0,-1),(-1,-1), 1.0, TEAL),
    # Padding
    ("TOPPADDING",   (0,1), (-1,-1), 5),
    ("BOTTOMPADDING",(0,1), (-1,-1), 5),
    ("LEFTPADDING",  (0,0), (-1,-1), 5),
    ("RIGHTPADDING", (0,0), (-1,-1), 5),
    ("VALIGN",       (0,0), (-1,-1), "TOP"),
])
tbl.setStyle(ts)
story.append(tbl)
story.append(sp(0.5))

# ═══════════════════════════════════════════════════════════════════════════
# SYSTEMATIC EXAMINATION BOX
# ═══════════════════════════════════════════════════════════════════════════
story.append(PageBreak())
story.append(section_bar("SYSTEMATIC NAIL EXAMINATION APPROACH", color=GREY_DARK))
story.append(sp(0.3))

exam_data = [
    ["STEP", "EXAMINE", "LOOK FOR"],
    ["1", "Nail plate", "Colour, thickness, surface texture, shape (flat/spoon/curved), ridging, pitting"],
    ["2", "Nail bed", "Colour (white/red/brown bands), onycholysis, subungual debris, haemorrhages"],
    ["3", "Lunula", "Size, shape, visibility; absent in Terry's nails"],
    ["4", "Nail fold\n(proximal + lateral)", "Cuticle integrity, pterygium formation, nail fold capillaries, paronychia"],
    ["5", "Fingertip", "Clubbing (Schamroth sign), calcinosis, digital infarcts"],
    ["6", "All 20 nails", "Symmetry; if all nails affected → systemic cause; one nail → local cause"],
]
hd2 = ParagraphStyle("TH2", fontSize=8, textColor=WHITE,
                     fontName="Helvetica-Bold", leading=10)
tc2 = ParagraphStyle("TC2", fontSize=8, textColor=GREY_DARK, leading=11)
exam_rows = []
for i, row in enumerate(exam_data):
    if i == 0:
        exam_rows.append([Paragraph(c, hd2) for c in row])
    else:
        exam_rows.append([Paragraph(c, tc2) for c in row])

exam_col_w = [(W-2*MARGIN)*x for x in [0.07, 0.22, 0.71]]
etbl = Table(exam_rows, colWidths=exam_col_w, repeatRows=1)
etbl.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0),  TEAL),
    ("BACKGROUND",   (0,1), (-1,-1), GREY_LIGHT),
    ("ROWBACKGROUNDS",(0,1),(-1,-1), [WHITE, GREY_LIGHT]),
    ("GRID",         (0,0), (-1,-1), 0.4, GREY_LINE),
    ("TOPPADDING",   (0,0), (-1,-1), 5),
    ("BOTTOMPADDING",(0,0), (-1,-1), 5),
    ("LEFTPADDING",  (0,0), (-1,-1), 6),
    ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    ("FONTNAME",     (0,1), (0,-1),  "Helvetica-Bold"),
    ("TEXTCOLOR",    (0,1), (0,-1),  TEAL),
    ("FONTSIZE",     (0,1), (0,-1),  10),
    ("ALIGN",        (0,0), (0,-1),  "CENTER"),
]))
story.append(etbl)
story.append(sp(0.4))

# ── Lab workup summary box ──────────────────────────────────────────────────
story.append(Paragraph("<b>KEY INVESTIGATIONS FOR NAIL DYSTROPHIES</b>", S["heading2"]))
story.append(sp(0.1))

labs = [
    ("Haematology", "CBC with differential, serum ferritin, serum iron, TIBC, transferrin saturation"),
    ("Biochemistry", "LFTs (albumin, bilirubin, GGT), renal function (eGFR, creatinine, urea), TFTs (TSH, free T4), HbA1c"),
    ("Immunology",  "ANA, ANCA, anti-dsDNA, antiphospholipid antibodies, complement (C3/C4)"),
    ("Microbiology","KOH microscopy, fungal culture, nail clipping biopsy, blood cultures (if endocarditis suspected)"),
    ("Imaging",     "CXR / CT chest (clubbing, yellow nail), echocardiogram (endocarditis, cardiac causes), lymphoscintigraphy"),
    ("Toxicology",  "Serum arsenic, thallium (Mees' lines with unexplained aetiology)"),
]
lab_rows = [[Paragraph(f"<b>{k}</b>", cell_style), Paragraph(v, cell_style)] for k, v in labs]
ltbl = Table(lab_rows, colWidths=[(W-2*MARGIN)*0.22, (W-2*MARGIN)*0.78])
ltbl.setStyle(TableStyle([
    ("GRID",         (0,0), (-1,-1), 0.4, GREY_LINE),
    ("BACKGROUND",   (0,0), (0,-1),  TEAL_LIGHT),
    ("TOPPADDING",   (0,0), (-1,-1), 5),
    ("BOTTOMPADDING",(0,0), (-1,-1), 5),
    ("LEFTPADDING",  (0,0), (-1,-1), 6),
    ("VALIGN",       (0,0), (-1,-1), "TOP"),
]))
story.append(ltbl)
story.append(sp(0.5))

# ── Footnote ────────────────────────────────────────────────────────────────
story.append(HRFlowable(width="100%", thickness=0.5, color=GREY_LINE))
story.append(sp(0.15))
story.append(Paragraph(
    "This quick reference was compiled from authoritative medical textbooks including Goldman-Cecil Medicine, "
    "Andrews' Diseases of the Skin, Fitzpatrick's Dermatology, Dermatology 2-Volume Set 5e, and Harrison's Principles "
    "of Internal Medicine 22e. Images © DermNet NZ and PMC Clinical VQA. For clinical decisions always confirm "
    "with current guidelines and individual patient context.",
    S["footnote"]
))

# ═══════════════════════════════════════════════════════════════════════════
# BUILD PDF
# ═══════════════════════════════════════════════════════════════════════════
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=MARGIN, rightMargin=MARGIN,
    topMargin=MARGIN + 0.4*cm, bottomMargin=1.3*cm,
    title="Nail Dystrophies & Systemic Causes — Quick Reference",
    author="Orris Medical AI",
    subject="Dermatology / Internal Medicine"
)

doc.build(story,
          onFirstPage=cover_banner,
          onLaterPages=later_pages)

print(f"\n✅  PDF created: {OUTPUT}")

Running Command

cd /home/daytona/workspace/nail-dystrophies && python3 generate_pdf.py 2>&1

Running Command

ls -lh /home/daytona/workspace/nail-dystrophies/Nail_Dystrophies_Quick_Reference…

Your PDF is ready:

📄

Nail Dystrophies Quick Reference

PDF Document · PDF

What's inside (4 pages)

Page 1 — Koilonychia + Clubbing

Clinical images for each, causes by system, key diagnostic tips

Page 2 — Beau Lines / Leukonychia Patterns / Psoriatic Nails / Lichen Planus

Terry's nails, Lindsay (half-and-half) nails, Muehrcke's & Mees' lines
Post-chemotherapy Beau + Mees combined image
Psoriatic nail matrix vs nail bed findings with NAPSI context

Page 3 — Master Reference Table (12 nail signs)

Nail Sign	Appearance	Systemic Causes	Investigation
Koilonychia	Spoon-shaped	Iron deficiency, Plummer-Vinson...	Ferritin, TIBC
Clubbing	Lovibond ≥180°	Lung Ca, IPF, CCF...	CXR, Echo
Beau lines	Transverse grooves	Sepsis, chemo, COVID...	Nail timing
Terry's	Proximal white	Cirrhosis, CCF, DM...	LFTs, albumin
Lindsay	Half-and-half	CKD / uraemia	eGFR, creatinine
… and 7 more

Page 4 — Systematic Examination Approach + Key Investigations

6-step nail exam protocol
Lab workup organised by category (haematology, biochemistry, immunology, microbiology, imaging, toxicology)

Sources: Goldman-Cecil Medicine, Andrews' Diseases of the Skin, Fitzpatrick's Dermatology, Dermatology 2-Vol Set 5e, Harrison's Principles 22e.

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