Role of Titanium in the Development of Yellow Nail Syndrome

Abstract

Yellow nail syndrome (YNS) is characterized by the triad of nail changes, lymphedema and respiratory tract involvement. Several hypotheses have been postulated to explain the findings in YNS including lymphatic drainage abnormalities along with microvasculopathy. The most recent hypothesis, proposed by Berglund and Calmark [Biol Trace Elem Res 2011;143:1-7], suggests a role of titanium dioxide in the development of YNS. This study showed elevated titanium levels (ranging from 1.1 to 170 μg/g of nail plate) in nail clippings or pieces of shed nail from 30 patients with YNS. Titanium was not found in the nails of healthy patients. Complete resolution was seen in 4 patients after removal of their titanium implants. Titanium dioxide is commonly found in cosmetics, sunscreens, medications, confectionaries and joint implants. Exposure to titanium can lead to its ions being released by galvanic action of dental gold or amalgam through the oxidative stress of fluorides. It is hypothesized that this galvanic interaction may lead to the yellow discoloration. At this point, cause and effect is speculative, but titanium may play a role in a subgroup of patients with YNS.

Titanium Pigment and Yellow Nail Syndrome

“…Dear Sir, Yellow nail syndrome (YNS) is considered a rare entity characterized by dystrophic yellowish nails, respiratory disorders, and lymphedema, which has appeared complete in approximately one third of cases [1][2][3][4] . The syndrome may be either autosomal dominant with a variable expression, or acquired due to mechanisms involving functional disturbances of lymphatic drainage as well as deposits of titanium in the nail plates [1][2][3][4] .…”

“…The syndrome may be either autosomal dominant with a variable expression, or acquired due to mechanisms involving functional disturbances of lymphatic drainage as well as deposits of titanium in the nail plates [1][2][3][4] . Some authors reported tumors in association with YNS, but this concomitance might occur only by chance [3,4] .…”

“…I have read with special interest the well-done manuscripts related to the significant role of titanium pigment in the development of YNS, recently published by Ataya et al [1] and Decker et al [2] . The patients were diagnosed with the incomplete presentation of YNS because of the lack of lymphedema [3,4] .…”

“…The practical usefulness of the studies by Ataya et al [1] and Decker et al [2] is really unquestionable; however, the commented findings seem to suggest additional research to better clarify the mechanisms of YNS.…”

“…Noteworthy was the lack of yellow nail changes, despite the chronic presence of titanium in the entire body. Interestingly, titanium was not found in the nails of healthy people who were exposed to titanium and gold [2] .…”