Indian Journal of Dermatology
  Publication of IADVL, WB
  Official organ of AADV
Indexed with Science Citation Index (E) , Web of Science and PubMed
Users online: 2764  
Home About  Editorial Board  Current Issue Archives Online Early Coming Soon Guidelines Subscriptions  e-Alerts    Login  
    Small font sizeDefault font sizeIncrease font size Print this page Email this page

Table of Contents 
Year : 2022  |  Volume : 67  |  Issue : 6  |  Page : 725-727
Tofacitinib for the treatment of twenty-nail dystrophy: A single case report

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 Publication23-Feb-2023

Correspondence Address:
Ravi Bhushan
Senior Resident, Department of Dermatology, Venereology and Leprology , Government Medical College and Hospital, Chandrapur, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.ijd_492_22

Rights and Permissions


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

How to cite this URL:
Dube V, Bhushan R. Tofacitinib for the treatment of twenty-nail dystrophy: A single case report. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 23];67:725-7. Available from:

   Introduction Top

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 Top

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

Click here to view
Figure 2: Post-treatment image after 6 months of oral Tofacitinib

Click here to view
Figure 3: Post-treatment image after 9 months of oral Tofacitinib

Click here to view

   Discussion Top

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


Conflicts of interest

There are no conflicts of interest.

   References Top

Tosti A, Bardazzi F, Piraccini BM, Fanti PA. Idiopathic trachyonychia (twenty-nail dystrophy): A pathological study of 23 patients. Br J Dermatol 1994;131:866-72.  Back to cited text no. 1
Samman PD. Trachyonychia (Rough nails). Br J Dermatol 1979;101:701-5.  Back to cited text no. 2
Dhayalan A, King BA. Tofacitinib citrate for the treatment of nail dystrophy associated with alopecia universalis. JAMA Dermatol 2016;152:492-3.  Back to cited text no. 3
Singh G, Haneer NS, Uday A. Nail changes and disorders among the elderly. Indian J Dermatol Venereol Leprol 2005;71:386-92.  Back to cited text no. 4
[PUBMED]  [Full text]  
Tosti A, Bellavista S, Iorizzo M, Vincenzi C. Occupational trachyonychia due to psoriasis: Report of a case successfully treated with oral acitretin. Contact Dermatitis 2006;54:123-4.  Back to cited text no. 5
Mittal R, Khaitan BK, Sirka CS. Trachyonychia treated with oral mini pulse therapy. Indian J Dermatol Venereol Leprol 2001;67:202-3.  Back to cited text no. 6
[PUBMED]  [Full text]  
Pierard GE, Pierard-Franchimont C. Dynamics of psoriatic trachyonychia during low-dose cyclosporine A treatment: A pilot study on onychochronobiology using optical profilometry. Dermatology 1996:192:116-9.  Back to cited text no. 7
Soda R, Diluvio L, Bianchi L, Chimenti S. Treatment of trachyonychia with tazarotene. Clin Exp Dermatol 2005;30:301-2.  Back to cited text no. 8
Schissel DJ, Elston DM. Topical 5-fluorouracil treatment for psoriatic trachyonychia. Cutis 1998;62:27-8.  Back to cited text no. 9
Tosti A, Piraccini BM, Cambiaghi S, Jorizzo M. Nail lichen planus in children: Clinical features, response to treatment, and long term follow-up. Arch Dermatol 2001;137:1027-32.  Back to cited text no. 10
Islam N, Leung PS, Huntley AC, Gershwin ME. The autoimmune basis of alopecia areata: A comprehensive review. Autoimmun Rev 2015;14:81-9.  Back to cited text no. 11
Xing L, Dai Z, Jabbari A, Cerise JE, Higgins CA, Gong W, et al. Alopecia areata is driven by cytotoxic T lymphocytes and is reversed by JAK inhibition. Nat Med 2014;20:1043-9.  Back to cited text no. 12
Shreberk-Hassidim R, Ramot Y, Zlotogorski A. Janus kinase inhibitors in dermatology: A systematic review. J Am Acad Dermatol 2017;76:745-53.  Back to cited text no. 13
Brown L, Skopit S. An excellent response to tofacitinib in a pediatric alopecia patient: A Case report and review. J Drugs Dermatol 2018;17:914-7.  Back to cited text no. 14
Craiglow BG, Liu LY, King BA. Tofacitinib for the treatment of alopecia areata and variants in adolescents. J Am Acad Dermatol 2017;76:29-32.  Back to cited text no. 15
Ferreira SB, Scheinberg M, Steiner D, Steiner T, Bedin GL, Ferreira RB. Remarkable improvement of nail changes in alopecia areata universalis with 10 months of treatment with tofacitinib: A case report. Case Rep Dermatol 2016;8:262-6.  Back to cited text no. 16
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.  Back to cited text no. 17
Iorizzo M, Haneke E. Tofacitinib as treatment for nail lichen planus associated with alopecia universalis. JAMA Dermatol 2021;157:352-3.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3]


Print this article  Email this article
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (755 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

   Case report
    Article Figures

 Article Access Statistics
    PDF Downloaded16    
    Comments [Add]    

Recommend this journal