Have your finger joints become enlarged and your nails changed? Let's learn about this Hypertrophic Osteoarthropathy!

Have you ever noticed that your fingertips or toes are unusually large, and your nails are either bent down or have an odd shape? Sometimes we don't pay much attention to these. However, if you see these symptoms, it could be a sign of a condition called 'Hypertrophic Osteoarthropathy' . This is also called HOA for short. The condition itself is not that dangerous, but other underlying conditions that cause it may need treatment. So, let's talk about this HOA in detail and learn more.

What is hypertrophic osteoarthropathy (HOA)?

Simply put, hypertrophic osteoarthropathy (HOA) is a condition that causes the tips of your fingers or toes to become swollen and rounded (clubbing) and changes in your nails. A person with HOA may:

• The tips of the fingers or toes become enlarged and swollen .
• The nails are bent down and take on a curved appearance, as if they have been pulled up.

HOA can sometimes begin in childhood or adolescence. For some people, it can also develop later in life. Although HOA itself is not harmful, if there is an underlying condition causing it, it is important to treat it.

What are the main types of this?

There are two main types of HOAs:

1. Primary Hypertrophic Osteoarthropathy (PHO): This type is genetic, meaning it can be inherited from parents to children.

2. Secondary Hypertrophic Osteoarthropathy (SHO): This type is caused by chronic conditions such as heart disease and lung disease. These conditions often cause low oxygen levels in your blood.

Who is more likely to develop this condition?

In fact, anyone, regardless of gender or race, can develop this condition called hypertrophic osteoarthropathy.

However, primary HOA (PHO) usually appears within the first year of life or during adolescence. PHO:

• It is more common among black people.
• It occurs more commonly in men.

Secondary HOA (SHO) is a condition that is usually seen most often in people between the ages of 55 and 75.

How common is this situation?

Researchers can't say exactly how many people have HOA. But it is known that between 95% and 97% of people with HOA have the secondary type (SHO) . This means that most people have these finger changes because of another condition.

Why is this HOA being formed? What are the reasons?

Let's see what causes this.

Reasons for a Primary HOA (PHO)

This is caused by genetic mutations that are present at birth . The child may inherit this genetic mutation from either the mother, the father, or both.

Reasons for secondary HOA (SHO)

The main cause of secondary HOA (SHO) is lung disease . When this condition is caused by lung disease, it is called Hypertrophic Pulmonary Osteoarthropathy (HPOA) .

The main lung disease that can cause HPOA is lung cancer , especially non-small cell lung cancer . In addition, other lung diseases that can cause HPOA include:

• Benign fibrous tumors of the pleura
• Chronic lung infections
• Cystic Fibrosis (a genetic disease that affects the respiratory system)
• Mesothelioma (cancer of the lining of the lungs)
• Cancer that has spread from other places and affects the lungs (Metastatic lung disease)
• Pulmonary arteriovenous malformation (abnormalities of the blood vessels in the lungs)
• Pulmonary Tuberculosis
• Sarcoidosis (cell clumps in various parts of the body)

There are other factors that can affect secondary HOA (SHO):

• Liver, bile, and gallbladder diseases (hepatobiliary conditions):
• Biliary Atresia (Bile Duct Obstruction in Young Children)
• Cancer
• Cirrhosis of the liver
• Primary Biliary Cholangitis
• Wilson's disease (copper accumulation in the body)
• Heart diseases:
• Atrial myxoma (a non-cancerous tumor that forms in the heart)
• Cyanotic Heart Disease (heart disease in which there is a decrease in oxygen in the blood)
• Infection of the inner lining of the heart (Infective Endocarditis)
• Gastrointestinal conditions:
• Abuse of laxatives
• Achalasia (a problem with the functioning of the esophageal sphincter)
• Cancer
• Familial Adenomatous Polyposis (small growths in the large intestine)
• Inflammatory Bowel Disease

In addition to this, several other conditions can cause SHO:

• Celiac Disease (gluten allergy)
• Intestinal infections such as dysentery
• Graves' Disease (hyperthyroidism)
• Hyperthyroidism
• Myelofibrosis (a disease of the bone marrow)
• POEMS syndrome
• Thymoma (a tumor of the thymus gland)

Imagine, someone you know has been coughing for a while and their fingers have changed like this, and only after seeing a doctor did they discover that it was a lung problem. So it's important to pay attention to these symptoms.

What are the symptoms of HOA?

The main symptom of HOA is clubbing or swelling of the fingertips or toes. This usually affects both sides of the body equally. You may notice things like:

• The tips of the fingers or toes are swollen and rounded .
• The wrinkles on the joints near the fingertips are disappearing.
• The nails are curved downwards and appear to be floating.
• The skin at the base of the nail becomes shiny and thin .
• Nails become soft .
• The tips of the fingers or toes are red and feel warm .

Other HOA features you may see include:

• Glandular hypertrophy. This can cause conditions such as acne, excessive sweating (hyperhidrosis), drooping upper eyelids (upper eyelid ptosis), and seborrheic dermatitis.
• Periostitis is inflammation of the membranes that cover bones. This can cause pain in the ankles, wrists, or knees.
• Swelling of the soft tissues of the legs (non-pitting edema).
• Bone thickening in the ankles and wrists.
• Thickening of the skin (Pachydermia). The skin on the face and scalp may become rough and have deep ridges.

What are the special characteristics of secondary HOA (SHO)?

In addition to the common symptoms of HOA mentioned earlier, people with secondary HOA (SHO) may also develop joint effusions . This is when extra fluid builds up in the tissues in and around the joints. Joint effusions can cause:

• Pain
• Redness
• Stiffness
• Swelling

Joint swelling associated with SHO is most commonly seen in the knees and wrists .

How do you find this? What tests do doctors do?

When you go to see a doctor, the first thing they'll do is check for clubbing on your fingertips or toes. In addition, they'll also look for the following during a physical exam:

• Have the facial features become rough?
• Are your legs swollen?
• Is there pain when you press on the ankles, knees, or wrists?
• Are the bones in the ankles and wrists thickening?

If the doctor suspects a condition called HOA, he or she may perform several tests, such as:

• Lovibond's profile sign:When you look at your finger from the side, you will usually see a wide "V"-shaped angle where the nail plate meets the skin fold at the base of the nail (proximal nail fold). If you have HOA, your nail is bent downward, increasing this angle. In a normal nail, this angle is 160 degrees or less. In a clubbed nail, it is 180 degrees or more.
• Phalangeal depth ratio: You have three bones (phalanges) in each finger. The bone that holds the nail (distal phalange) is usually shorter than the bone next to it (middle phalange). If you have HOA, your middle phalange is shorter than your distal phalange.
• Schamroth's sign: Place the nails of your index fingers together. Look for a diamond-shaped gap (window) between the base of the nail and the cuticles. If there is no gap, you likely have HOA.

Additional tests to detect secondary HOA (SHO)

If the doctor suspects that another underlying medical condition is causing the HOA, he or she may suggest several other tests:

• Angiography (blood vessel examination)
• Arterial blood gas test
• Blood tests
• Bone scan
• Chest X-ray
• CT scan (Computed Tomography scan) or ultrasound scan (Ultrasound)
• Echocardiogram or Electrocardiogram (EKG)
• MRI Scan (MRI - Magnetic Resonance Imaging)
• Pulmonary function testing

These tests can help your doctor find the cause of your HOA. If a scan shows an abnormal growth (like a tumor), your doctor may also suggest a biopsy (taking a sample of cells and testing them). This will help determine the exact cause of the growth.

How is this treated?

Treatment methods vary depending on the type of HOA.

Treatment of primary HOA (PHO)

If you don't have pain or your symptoms aren't severe, you may not need any special treatment for primary HOA (PHO). However, if you have symptoms, you may be able to use medications such as:

• Non-steroidal anti-inflammatory drugs (NSAIDs)
• COX-2 inhibitors
• Bisphosphonates
• Octreotide

Treatment of secondary HOA (SHO)

When treating secondary HOA (SHO), the main thing is to treat the underlying cause . Treatment may include:

• Antimicrobial therapy for the treatment of tuberculosis
• Chemotherapy to treat lung cancer
• Liver grafts or liver transplantation for liver disease
• Lung transplant surgery for cystic fibrosis
• Radiofrequency ablation for lung tumors (using heat to destroy tumors)
• Surgery for heart disease or lung cancer

If the underlying condition causing the SHO cannot be treated, the doctor may suggest medications to control the symptoms.

How long does it take to recover from treatment?

This really depends on the type of HOA you have, the severity of the condition, and the treatment you receive. Once the underlying condition is treated, clubbing may go away quickly.

Is there anything we can do to reduce the occurrence of this?

Primary HOA (PHO) risk

Since PHO is genetic, there is nothing we can do to reduce its formation.

Secondary HOA (SHO) risk

To reduce the risk of developing SHO, it is very important to follow a healthy lifestyle . This is especially important if you are at risk for heart disease or lung disease. Here are some things you can do:

• Maintaining a healthy weight.
• Eating a heart-healthy diet.
• Exercising regularly.
• Limiting alcohol and drug use.
• Quitting smoking. This is very important, because smoking is a major cause of many lung diseases.
• Reducing stress.

What will the future hold for someone with an HOA?

For someone with a primary HOA (PHO)

PHO may stop getting worse on its own. Sometimes, especially after adolescence, it may even get better completely.

For someone with a secondary HOA (SHO)

If the underlying cause is successfully treated, the condition can be completely cured. However, if the underlying cause cannot be successfully treated (for example, a serious cancer), the condition may persist.

What happens if the HOA situation lasts a long time?

If the HOA situation has been going on for a long time, you may experience things like:

• Loss of range of motion in joints
• Osteoarthritis (joint pain)
• Pain

However, remember that many of these symptoms can be controlled with proper treatment .

If there is an HOA, how do you take care of yourself?

If you have HOA, the best thing you can do is continue to take the treatment you are given to control your symptoms. It is very important to follow your doctor's instructions.

When should you see a doctor?

You should be careful about these things:

• After treatmentIf clubbing symptoms recur, see a doctor. This may indicate a recurrence of the underlying condition.
• If you have concerns about side effects from treatment .
• If no improvement is seen despite treatment for a while.

In such cases, your doctor may suggest other treatments that are suitable for you.

Summary: Things to Remember (Take-Home Message)

Okay, let's just briefly recall what we've talked about.

Hypertrophic osteoarthropathy (HOA) is a condition in which the tips of the fingers become swollen and the nails become deformed. It can be primary (genetic) or secondary (caused by another disease). The main causes of secondary HOA are lung and heart disease.

• Symptoms: Swelling of the fingertips, ingrown toenails, joint pain, and thickening of the skin.
• Diagnosis: Medical examination, special tests (Lovibond, Shamroth scores), and scans to look for the underlying cause.
• Treatment: For PHO, medication is given according to symptoms. For SHO, the main thing is to treat the underlying disease.
• Most importantly: If you notice any changes in your fingers, don't ignore them and seek medical advice. Because, while HOA is not dangerous, the underlying disease that causes it can be dangerous.

I hope you find this information useful. Stay healthy!

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