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E-IJD CASE REPORT
Year : 2015  |  Volume : 60  |  Issue : 4  |  Page : 420
Onychomadesis with lichen planus: An under-recognized manifestation


Department of Dermatology, University College of Medical Sciences and GTB Hospital, Dilshad Garden, New Delhi, India

Date of Web Publication10-Jul-2015

Correspondence Address:
Dr. Chander Grover
420-B, Pocket 2, Mayur Vihar, Phase-1, New Delhi - 110 091
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.160512

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   Abstract 

Onychomadesis or proximal separation of the nail pate usually results from severe, generalized dermatoses like bullous diseases, hand foot and mouth disease, varicella or severe cutaneous drug reactions. Although lichen planus (LP) produces varied nail manifestations (longitudinal onychorrhexis, onychoschizia, nail pigmentation, pterygium etc.), to the best of our knowledge, onychomadesis as a manifestation of nail LP is not recorded. This report presents two children with onychomadesis arising with generalized eruptive LP.


Keywords: Intramatricial injection, Nail matrix, Triamcinolone acetonide


How to cite this article:
Grover C, Vohra S. Onychomadesis with lichen planus: An under-recognized manifestation. Indian J Dermatol 2015;60:420

How to cite this URL:
Grover C, Vohra S. Onychomadesis with lichen planus: An under-recognized manifestation. Indian J Dermatol [serial online] 2015 [cited 2020 Jun 5];60:420. Available from: http://www.e-ijd.org/text.asp?2015/60/4/420/160512

What was known?

  • Onychomadesis is a manifestation of multitude of disorders affecting the nail, including bullous diseases, severe adverse drug reactions, and viral infections.
  • Lichen planus preferentially affects the matrix in the nail unit. Varied manifestations in the form of onychorrhexis, melanonychia, pterygiuym etc., have been described.



   Introduction Top


Onychomadesis is the spontaneous proximal separation of the nail pate (NP), considered by many to be a progression of Beau's lines. [1] It usually results from generalized dermatoses like bullous disorders; viral infections like hand, foot and mouth disease or varicella; severe cutaneous drug reactions; intense X-ray therapy; acute and chronic paronychia; [2] or severe psychological distress. [3]

Lichen planus (LP) produces varied nail manifestations in the form of longitudinal onychorrhexis, onychoschizia, nail pigmentation, pterygium, etc. [4] However, to the best of our knowledge and belief, onychomadesis as a manifestation of nail LP has hitherto not been reported. We report two interesting cases of onychomadesis arising with generalized eruptive LP in children. The response to an early institution of intra-matricial corticosteroid therapy is also highlighted.


   Case Reports Top


Case 1

Patient 1 was a 7-year-old girl with multiple, itchy, violaceous eruptions over both hands and feet for 6 months. There was no history of photosensitivity, oral mucosal involvement, hair or nail loss accompanying or preceding the lesions. On examination, multiple flesh-colored as well as violaceous, papules and annular plaques, over dorsae of hands and feet were seen with mild overlying scaling. Her nails, mucosae, palms and soles, scalp and other hair bearing areas were normal. A lesional biopsy confirmed the diagnosis of LP. With normal hematological, biochemical investigations and serum G6PD activity, she was stated on dapsone (50 mg daily), oral antihistaminics, and topical mid potency steroid. However, 2 weeks later, discoloration and surface irregularity was observed in the proximal part of multiple nails [Figure 1]a] which progressed to a clearly visible defect in the juxtamatricial portion of NP [Figure 1]b]. Similar changes were seen in toenails after 4 weeks [Figure 2]a]. The parents or the child were not ready for a nail biopsy. The need for early initiation of steroid therapy was explained, and they agreed for intra-matricial injections. Triamcinolone acetonide (5 mg/ml) was injected in the proximal nail fold area of affected finger and toenails at 4 weekly intervals. Over next 4 months, new skin lesions stopped appearing, and older ones showed signs of regression [Figure 1]c]. The treated nails improved slowly and did not develop permanent loss or scarring. A visibly thinner NP was appreciated which normalized over further 3 months.
Figure 1: Hand nails of patient 1. (a) At the start of therapy. Multiple annular lesions of lichen planus appreciated. The thumb nail shows an area of discoloration proximally. (b) After 4 weeks, a visible defect in the proximal nail plate can be appreciated (onychomadesis). (c) After 16 weeks of intra-matricial steroid therapy. The nail plate is improved and there is no evidence of scarring

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Figure 2: Toe nails of patient 1 and patient 2

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Case 2

Patient 2 was a 12-year-old boy, with eruptive LP of 3 months duration. He presented with extensive lesions, [Figure 2]b showing koebnerization, over the dorsae of hands and feet and few lesions over the trunk. The nails were essentially normal except for the left great toe nail that had discoloration and proximal painless separation of NP. This child was also started on oral dapsone and intra-matricial injections of triamcinolone acetonide (5 mg/ml) in the affected nail, following which improvement was noticed.


   Discussion Top


Onychomadesis results from a temporary arrest in the proximal nail matrix proliferation resulting in separation of proximal NP by a whole-thickness sulcus. [5] Clinically, a slowly appearing cleavage of NP, which has the potential to progress to complete separation, is seen. Less frequently, a latent form may be noticed where temporary complete inhibition of nail growth shows a transverse split of NP, in the form of a deep Beau's line, nevertheless the nail continues to grow. Causes of onychomadesis reported in literature include local factors, cytotoxic drugs, and systemic diseases. Local factors like acute paronychia and local trauma are the most commonly responsible. [4] Systemic diseases like Kawasaki disease, scarlet fever, hand-foot and mouth disease, thrombocytopenia and systemic lupus erythematosus have been reported to produce onychomadesis. [5],[6] Various drugs implicated in the causation include antineoplastics and valproate. [7] Onychomadesis can also be idiopathic or familial. [6] Nail involvement reportedly occurs in 10% of patients with LP with fingernails being more frequently affected. [8] It is more common in adults, and usually several nails are affected. In the vast majority, nail LP presents with so called "typical" matrix involvement producing nail thinning, longitudinal ridging, onychoschizia, and fissuring. [5] Pterygium formation is a possible outcome indicating matrix scarring. Less commonly, LP of the nail bed is seen producing onycholysis or subungual hyperkeratosis. Other reported features include yellow nail syndrome-like changes, [8] trachyonychia, [9] idiopathic atrophy, [10] nail bed erosions and pigmentary changes. [4] On the basis of a strong temporal correlation between the onset of LP and onychomadesis in these two patients (in the absence of any other local or systemic factors), it is apparent that nail LP produced onychomadesis. Though, nail biopsy would have reinforced the finality of this association, it was neither possible nor ethical in both the cases under the given circumstances. To best of our knowledge, onychomadesis as a presenting manifestation has previously not been reported.

Lichen planus of nail matrix is slowly progressive but potentially scarring, the most dreaded complication being permanent anonychia and pterygium. Hence, prompt treatment with steroids either systemic or intra-matricial is required, producing near total regression of early changes. [11],[12] Both our patients responded favorably with regrowth of a thinner but normal appearing nails.

To conclude, we wish to highlight onychomadesis as a manifestation of nail LP. LP induced severe inflammation in the matrix leading to a temporary growth arrest was the possible mechanism. A favorable response to therapy suggests that an early recognition and prompt treatment can help reverse changes. Onychomadesis may be not so rare, but an under-recognized and under-reported manifestation of nail LP. Well-designed clinical studies of nail changes in LP may help clarify this issue.



 
   References Top

1.
Hardin J, Haber RM. Idiopathic sporadic onychomadesis: Case report and literature review. Arch Dermatol 2012;148:769-70.  Back to cited text no. 1
    
2.
Relhan V, Goel K, Bansal S, Garg VK. Management of chronic paronychia. Indian J Dermatol 2014;59:15-20.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Bettoli V, Zauli S, Toni G, Virgili A. Onychomadesis following hand, foot, and mouth disease: A case report from Italy and review of the literature. Int J Dermatol 2013;52:728-30.  Back to cited text no. 3
    
4.
Bracho MA, González-Candelas F, Valero A, Córdoba J, Salazar A. Enterovirus co-infections and onychomadesis after hand, foot, and mouth disease, Spain, 2008. Emerg Infect Dis 2011;17:2223-31.  Back to cited text no. 4
    
5.
Piraccini BM, Saccani E, Starace M, Balestri R, Tosti A. Nail lichen planus: Response to treatment and long term follow-up. Eur J Dermatol 2010;20:489-96.  Back to cited text no. 5
    
6.
Bodman MA. Nail dystrophies. Clin Podiatr Med Surg 2004;21:663-87, viii.  Back to cited text no. 6
    
7.
Mehra A, Murphy RJ, Wilson BB. Idiopathic familial onychomadesis. J Am Acad Dermatol 2000;43:349-50.  Back to cited text no. 7
    
8.
Poretti A, Lips U, Belvedere M, Schmitt B. Onychomadesis: A rare side-effect of valproic acid medication? Pediatr Dermatol 2009;26:749-50.  Back to cited text no. 8
    
9.
Baran R. Lichen planus of the nails mimicking the yellow nail syndrome. Br J Dermatol 2000;143:1117-8.  Back to cited text no. 9
    
10.
Blanco FP, Scher RK. Trachyonychia: Case report and review of the literature. J Drugs Dermatol 2006;5:469-72.  Back to cited text no. 10
    
11.
Grover C, Bansal S, Nanda S, Reddy BS. Efficacy of triamcinolone acetonide in various acquired nail dystrophies. J Dermatol 2005;32:963-8.  Back to cited text no. 11
    
12.
Dehesa L, Tosti A. Treatment of inflammatory nail disorders. Dermatol Ther 2012;25:525-34.  Back to cited text no. 12
    

What is new?

  • Onychomadesis can be a manifestation of nail lichen planus and generally signifies acute progression and severe suppression of nail matrix proliferation.
  • Early recognition and institution of therapy can help reverse potentially permanent nail los.


    Figures

  [Figure 1], [Figure 2]



 

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