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Table of Contents 
Year : 2016  |  Volume : 61  |  Issue : 3  |  Page : 341-342
Worn-down nails affecting toe nails

1 Department of Dermatology, Katihar Medical College, Katihar, Bihar, India
2 Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
3 Consultant Dermatologist, Bombay Missionary Hospital, Mumbai, Maharashtra, India

Date of Web Publication13-May-2016

Correspondence Address:
Anupam Das
Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5154.182432

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How to cite this article:
Kumar P, Savant SS, Hassan S, Das A, Barman PD. Worn-down nails affecting toe nails. Indian J Dermatol 2016;61:341-2

How to cite this URL:
Kumar P, Savant SS, Hassan S, Das A, Barman PD. Worn-down nails affecting toe nails. Indian J Dermatol [serial online] 2016 [cited 2022 Aug 10];61:341-2. Available from:


The nail plate, being a dead keratinized structure, cannot repair itself following an injury and hence, repetitive injuries may lead to permanent nail plate diseases. These nail plate diseases may be cured on their own when the nail grows out or is cut away. One such disease affecting nail plate is worn-down nails or bidet nails. Bidet nails were first described by Baran and Moulin in three unrelated women in whom the distal portions of nail plates were worn-down by frequent rubbing against porcelain of the bidet (type of sink intended for washing the genitalia, inner buttocks, and anus) while cleaning their genital area. Clinically, nails were remarkable for a triangular thinning of the distal nail plate (with its base at the free edge of the nail) and erythema.[1] Similar nail changes were noted by Piraccini et al . in 14 patients who did not use bidets. However, seven out of 14 patients gave a history of rubbing their nails against something (clothes in case of six persons who were tailors). Thirteen out of 14 patients had the affection of nails of the dominant hand only and all of them improved with conservative treatment.[2] Other associated factors reported include tic disorder,[3] trauma from nail filing after acrylic nail removal,[4] and chronic itchy conditions.[5] Considering the varied etiologies, “worn-down nails” appear to be a more appropriate term to describe this entity. So far, only finger nail affection has been reported in the literature. Here, we report a case of 25-year-old male who developed worn-down nails affecting nails of both great toes from ill-fitting shoes.

A 25-year-old man, salesman by profession, presented with asymptomatic nail plate splitting and redness affecting nails of both great toes of 1-year duration. The lesions started as redness and splitting at the most distal end and progressed over a few months to attain the present status [Figure 1]. However, the lesion has been static for the last 6 months, despite the continuation of his usual activities. He gave a history of discomfort during walking, but there was no pain at rest. He was not used to cutting his nails regularly and used to keep nails long. He was otherwise healthy and would not smoke or drink. On examination, the nails of both great toes showed a triangular area of nail thinning and redness with its base on the distal free end. The margins of this triangular area were marked by a thin whitish line. There was a longitudinal splitting of the nail extending from the distal free end to midway of the nail plate. No other nails of the toes or hands were affected. The rest of the mucocutaneous examination was unremarkable except for polymorphous light eruption over the neck. A diagnosis of worn-down nails was made clinically, and lichen planus of the nail was considered in the differential. The sample for histopathology was collected from the nail bed of affected area. The histopathology findings were nonspecific [Figure 2]. The patient was asked to keep nails short, and to use footwear with spacious toe box area. He was subsequently lost to follow-up.
Figure 1: Distal most part of toe nails showing triangular thinning, central longitudinal split and erythema

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Figure 2: Nail bed showing mild nonspecific inflammation (H and E, ×100)

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Worn-down nails are caused by repetitive mechanical trauma to nail plate and present as an area of marked triangular thinning and erythema of the distal nail plate.[2] However, all subjects exposed to repetitive mechanical trauma as described above do not necessarily develop worn-down nails, indicating an individual intrinsic susceptibility to nail plate damage.[6] The diagnosis is made clinically. Onychoscopy may be helpful in doubtful cases, and shows dilated capillaries and pinpoint hemorrhages.[3] The role of histopathology is limited and is needed only to rule out differential diagnoses. Longitudinal splitting may be traumatic in origin or may be noted in different conditions such as lichen planus, lichen striatus (affecting heminail), Darier's disease, and space occupying lesions such as myxoid cysts and warts. The key to successful treatment is based on keeping the nails short (to avoid damage to nail plate)[2] and cessation of behavior responsible for the recurring trauma to the nail plate.[4],[7] Oral biotin may help in some cases by increasing nail plate strength, making the nail plate more resistant to trauma.[2]

A very similar presentation is lacquer nails which was described by Rigopoulos et al . in patients with onychomycosis on treatment with topical antifungal nail lacquers. Lacquer nail results from the excessive rubbing of the nail plate with nail filers provided with the kit. The changes included thinning of the nail plate, triangular onycholysis (with the base at the free edge of the nail, where the thinning is maximal), median longitudinal onychorrhexis, and subungual erythema and were mostly seen in women, fearful of losing their nail due to onychomycosis.[8] We believe lacquer nails and worn-down nails essentially represent the same condition-nail dystrophy caused by repetitive mechanical trauma.


The authors would like to thank Prof. Robert Baran for his valuable inputs in the case review. The authors would like to thank Dr. Sherina Laskar for her help with reviewing the manuscript.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Baran R, Moulin G. The bidet nail: A French variant of the worn-down nail syndrome. Br J Dermatol 1999;140:377.  Back to cited text no. 1
Piraccini BM, Tullo S, Iorizzo M, Rech G, Tosti A. Triangular worn down nails: Report of 14 cases. G Ital Dermatol Venereol 2005;140:161-4.  Back to cited text no. 2
Patrizi A, Tabanelli M, Neri I, Pazzaglia M, Piraccini BM. Worn-down nail syndrome in a child. J Am Acad Dermatol 2008;59 2 Suppl 1:S45-6.  Back to cited text no. 3
Wu TP, Morrison BW, Tosti A. Worn down nails after acrylic nail removal. Dermatol Online J 2015;21. pii: 13030/qt5781m7vc.  Back to cited text no. 4
Tosti A, Baran R, Dawber RP, Haneke E. Nail configuration abnormalities. In: Baran R, Dawber RR, Haneke E, Tosti A, Bristow I, editors. A Text Atlas of Nail Disorders Techniques in Investigation and Diagnosis. 3rd ed. London: Martin Dunitz; 2003. p. 44-6.  Back to cited text no. 5
Lubach D, Beckers P. Wet working conditions increase brittleness of nails, but do not cause it. Dermatology 1992;185:120-2.  Back to cited text no. 6
Dogra S, Yadav S. What's new in nail disorders? Indian J Dermatol Venereol Leprol 2011;77:631-9.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
Rigopoulos D, Charissi C, Belyayeva-Karatza Y, Gregoriou S. Lacquer nail. J Eur Acad Dermatol Venereol 2006;20:1153-4.  Back to cited text no. 8


  [Figure 1], [Figure 2]


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