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SHORT COMMUNICATION |
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| Year : 2022 | Volume
: 67
| Issue : 6 | Page : 725-727 |
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| Tofacitinib for the treatment of twenty-nail dystrophy: A single case report |
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Vineet Dube1, Ravi Bhushan2
1 Consultant Dermatologist, Chandrapur, Maharashtra, India
2 Senior Resident, Department of Dermatology, Venereology and Leprology, Government Medical College and Hospital, Chandrapur, Maharashtra, India
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Ravi Bhushan
Senior Resident, Department of Dermatology, Venereology and Leprology , Government Medical College and Hospital, Chandrapur, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.ijd_492_22
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 Abstract | | |
Twenty nail dystrophy refers to the condition of trachyonychia affecting all the twenty nails. The term trachyonychia is used to describe thin brittle nails with excessive longitudinal ridging. Treatment of twenty nail dystrophy is difficult due to poor bioavailability of drugs in nails. Tofacitinib is novel JAK-STAT inhibitor that has been used successfully for the treatment of nail dystrophy with alopecia areata suggests the possibility of the drug being used for twenty nail dystrophy.
Keywords: Twenty nail dystrophy, Trachyonychia, Tofacitinib
How to cite this article:
Dube V, Bhushan R. Tofacitinib for the treatment of twenty-nail dystrophy: A single case report. Indian J Dermatol 2022;67:725-7 |
| Introduction | |  |
Twenty-nail dystrophy (TND) is the term that is used to describe trachyonychia in all 20 nails.[1] Trachyonychia is a condition where nails are rough, brittle and opaque with diffuse ridging ranging from small shiny superficial pits in mild cases to sandpaper-like appearance in severe cases.[2] Treatment for TND is very difficult and as per our knowledge, there has been no gold standard treatment for this. Tofacitinib, which is a JAK-STAT inhibitor, is one of the novel drugs that has been used for the treatment of TND or trachyonychia, especially for those cases associated with alopecia areata, psoriasis or psoriatic arthritis.[3] Thus, we report a recalcitrant case of TND that has been successfully treated by oral Tofacitinib.
| Case report | | |
A 13-year-old male patient weighing 38 kg presented with complaints of the roughness of nails with multiple longitudinal ridging and sandpaper-like appearance in all the fingers of hands and feet for 2 years [Figure 1]. The patient had no other dermatological or systemic involvement. The patient's parents refused nail biopsy; therefore, he was clinically diagnosed with a case of TND, which was idiopathic. The patient was started on oral cyclosporine after all the investigation in the dose of 5 mg/kg in three divided doses for 3 months, but no improvement was observed. The patient was subsequently given oral mini pulse therapy of Betamethasone and monthly intramatrix injection of Triamcinolone 5 mg/mL for 3 months without any improvement. Then after all baseline investigations like complete blood count (CBC), liver function test (LFT), renal function test (RFT), fasting lipid profile, human immunodeficiency virus (HIV), Hepatitis B virus (HBV), Hepatitis C virus (HCV) and Manteaux test for tuberculosis screens, oral Tofacitinib was started in a dose of 5 mg twice daily for 6 months, it was tapered to 2.5 mg twice a day for further 3 months. CBC, LFT, RFT and fasting lipid profile were repeated after 1, 3, 6 and 9 months, respectively. There was significant improvement observed in all 20 nails with decreased longitudinal ridging and reappearance of smooth and shiny nature after 6 and 9 months, respectively [Figure 2] and [Figure 3]. | Figure 1: Pre-treatment image of patient presenting with Twenty-nail dystrophy with sandpaper-like appearance
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| Discussion | | |
TND can be a manifestation of a variety of disorders, which can be genetic, acquired or idiopathic. Some common disorders that might be associated with TND are Alopecia areata, Atopic dermatitis, Lichen planus, Dyskeratosis congenita, Ichthyosis Vulgaris, Incontinentia Pigmenti, etc.[4] Treatment for TND is difficult due to poor penetration of drugs both via systemic and local routes. Some of the treatment options that have been illustrated in various case reports are oral retinoids (Acitretin), Betamethasone, Cyclosporine, topical retinoids (Tazarotene), 5-fluorouracil and intramatrix injection of Triamcinolone.[5],[6],[7],[8],[9],[10]
Tofacitinib is a JAK 1 and 3 inhibitor that has yielded promising results acting as targeted anti-inflammatory drugs.[11] Nail matrix is epithelial keratin-producing structure and nail matrix keratinocytes show similar gene expression like hair follicles keratinocytes. Like hair follicles, they express interleukin-15, NKG2D ligands and major histocompatibility complex molecules that lead to the recruitment and activation of interferon γ-producing, NKG2D-expressing CD8 T cells to target nail matrix keratinocytes. JAK signalling mediates interleukin 15 activation of T cells and the use of JAK inhibitor will inhibit effector T cells targeting nail matrix keratinocytes and reverse nail dystrophy.[3],[12] Common adverse effects noted with JAK inhibitors are nasopharyngitis, upper respiratory infections, cutaneous infections, gastrointestinal complaints, herpes zoster and laboratory abnormalities such as anaemia and neutropenia but as Tofacitinib is specifically JAK 1 and 3 inhibitors, it is considered safer than other JAK inhibitors.[13] With regular monitoring, it can also be given in adolescence or childhood.[14] Therefore, all baseline investigations like complete blood count, comprehensive metabolic panel, fasting lipid panel, HBV, HCV, HIV and tuberculosis screens were performed and even followed up after 1, 3 and 6 months.[15]
Earlier Tofacitinib has shown significant improvement in cases of nail dystrophy associated with alopecia universalis[3],[16],[17] or nail lichen planus with alopecia areata[18] with the same mechanism as mentioned. As per our knowledge, this is the first case where oral Tofacitinib has been used successfully for idiopathic Twenty-nail dystrophy without any dermatological association.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 17. | Dube V. Recovery of alopecia universalis with associated nail dystrophy treated with tofacitinib: A 6-year-old child's case report. Int J Trichology 2021;13:32-3. |
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[Figure 1], [Figure 2], [Figure 3] |
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