A Rare Case Report: Twenty Nail Dystrophy in Child

Marissa Astari, Afif Nurul Hidayati, Yuri Widia, Linda Astari, Sunarso Suyoso, Evy Ervianti

Department of Dermato-Venereology, Dr. Soetomo Teaching Hospital / School of Medicine, Universitas Airlangga,

Surabaya, Indonesia

Keywords: Trachyonychia, nail distrophy.

Abstract: Twenty nail dystrophy (trachyonychia) is a nail sign that can be idiopathic but likely reflects alopecia areata,

psoriasis, dermatitis, or lichen planus of the nail. Characterized by nail roughness due to excessive

longitudinal ridging (sandpaper nails) and more common in children.(1) A 6-years old girls presented to the

Sutomo General Hospital outpatient clinic complaint of yellowish discoloration and roughness of all his

fingernails and toenails, starting with the thumbs and simultaneously since four years earlier. There were

history of atopic in her family. This report highlights the challenges faces for investigation of the underlying

cause.

1 INTRODUCTION

Twenty nail dystrophy also known as trachyonychia

was first mentioned by Hazelrigg et al. in 1977

because it was initially described as uniformly

affecting all twenty nail and toenails (Tongdee et al.,

anon). However since not all 20 nails are always

affected in this condition, it has since been termed

“trachyonychia” (Alkiewicz, 1950). Trachyonychia

is a disorder of the nail unit that most commonly

presents with rough, longitudinally ridged nails

(opaque trachyonychia) or less frequently, uniform,

opalescent nails with pits (shiny trachyonychia). The

term trachyonychia refers to ‘rough nails.’ The

appearance has also been likened to the nails being

rubbed with sandpaper, and has therefore also been

referred to colloquially as ‘sandpapered nails.’

Trachyonychia can occur in patients of all ages,

though children tend to be more frequently affected.

Girls and boys are affected equally (Karakayali et

al., 1999). The condition can evolve idiopathically

as well as in association with a wide variety of

dermatologic and nondermatologic diseases.

Severity of disease may vary between nails, but

generally, the nails evolve over time into a muddy,

white-grayish discoloration.(Tongdee et al., anon).

2 CASE

A 6-years old girls presented to the Sutomo General

Hospital outpatient clinic complaint of yellowish

discoloration and roughness of all his fingernails and

toenails, starting with the thumbs and

simultaneously since four years earlier. At the time

of presentation, the nails were dull, yellow,

lusterless, and opaque with excessive longitudinal

ridging and had a rough surface. She also complaint

about the dry skin but no skin lesions elsewhere on

the body. Potassium hydroxide smear and fungal

culture of the nail scrapping were negative. A biopsy

from nail clipping of the right finger was taken. It

showed stain positive for spores. Other blood

investigation showed high IgE serum (1,872 IU/mL).

3 DISCUSSION

Trachyonychia is a disorder of the nail unit that most

commonly presents with rough, longitudinally

ridged nails (opaque trachyonychia) or less

frequently, uniform, opalescent nails with pits (shiny

trachyonychia). The term trachyonychia refers to

‘rough nails.’ The appearance has also been likened

to the nails being rubbed with sandpaper, and has

therefore also been referred to colloquially as

‘sandpapered nails.’ It can involve from one nail up

to all twenty nails (Haber et al., 2016).

Astari, M., Hidayati, A., Widia, Y., Astari, L., Suyoso, S. and Ervianti, E.

A Rare Case Report: Twenty Nail Dystrophy in Child.

DOI: 10.5220/0008161205230525

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 523-525

ISBN: 978-989-758-494-7

523

In particular, onychimycosis may appear very

similar to trachyonychia, so early appropriate

evaluation for that disorder is needed. There are two

different subtypes of trachyonychia categorized by

their clinical appearance and severity (Baran, 1981).

Opaque trachyonychia, the more severe type,

characterized by rough nails that appear to have been

rubbed by sandpaper. Nail changes in the case of it

is produced by a remittent, waxing and waning

inflammatory insult to the matrix that never ceases

(Tosti et al., 1995). Shiny trachyonychia

characterized by shiny, opalescent nails with

numerous pits. There is an intermittent, focal, and

regularly recurrent inflammatory insult to the matrix

that is separated by periods of normal matrix

function.

Figure 1: The opaque trachyonychia involving all the 20 nails..

Trachyonychia was occurred exclusively in

children with the peak age of onset between the age 3

and 12 years.

Trachyonychia is a clinical diagnosis and there is

no indication for a nail biopsy because it never

causes permanent nail damage or pterygium, and for

this reason, there is no necessity for nail matrix

punch or longitudinal nail biopsy, which is invasive

and cause scarring (Jacobsen et al., 2016). The most

common features of histopathological examination

are spongiosis of inflammatory cells into the nail

epithelia.

Treatment for trachyonychia usually for a

cosmetic reasons and patients may often improve

withput any treatment. In patients who have an

associated underlying disease, treatments for the

associated disease may be beneficial in improving the

appearance of the nails. Since trachyonychia is a

benign confition and children tend to have shorter

disease courses, pediatric patients warrant a more

conservative approach. If children are bothered or

parents push for treatment we cas use the algorithm

for treating trachyonychia. It begins with

observation/active nonintervention followed by a trial

period of topical treatments (3-4 months). If the

patient requests further treatment, nail unit steroid

injection may be comsidered (Haber et al., 2016).

Table 1: Dermatologic diseases associated with trachyonychia (Haber et al., 2016).

Commonly associated diseases Uncommonly associated disease

Alopecia areata/alopecia universalis

Lichen planus

Psoriasis

Icthyosis vulgaris

Vitiligo

Atopic dermatitis

Pemphigus vulgaris

Incontinentia oigmenti

Congenital cutaneous candidiasis

Darier’s disease

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