Role of Titanium in the Development of Yellow Nail Syndrome

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.