Figure 330

Diffuse pitting of the whole nail in psoriasis.

Nail Pitting Causes

Figure 3.31

Multiple nail pits—'rippled' effect in alopecia areata. Table 3.3 lists the causes of nail pitting.

Figure 3.31

Multiple nail pits—'rippled' effect in alopecia areata. Table 3.3 lists the causes of nail pitting.

TRACHYONYCHIA (ROUGH NAILS)

The term 'twenty-nail dystrophy' or trachyonychia describes a spectrum of nail plate surface abnormalities that result in nail roughness (Figures 3.32-3.38). Patients with trachyonychia can be divided into two main groups:

1 Trachyonychia and a past history or clinical evidence of alopecia areata.

2 Isolated nail involvement (idiopathic trachyonychia).

Alopecia Effect Nails

Figure 3.32

Trachyonychia (rough nails) due to alopecia areata.

Figure 3.32

Trachyonychia (rough nails) due to alopecia areata.

Trachyonychia Nail

Figure 3.33

Trachyonychia—shiny variety.

Figure 3.33

Trachyonychia—shiny variety.

Reason Rough Nails

Figure 3.34

Trachyonychia—idiopathic.

Figure 3.34

Trachyonychia—idiopathic.

Lichen Knuckles

Figure 3.35

Trachyonychia—involvement of a single nail.

Figure 3.35

Trachyonychia—involvement of a single nail.

Lichen Planus Knuckles

Figure 3.36

Trachyonychia in a manual worker.

Figure 3.36

Trachyonychia in a manual worker.

Benign Familial Pemphigus

Figure 3.37

Trachyonychia—lichen planus.

Twenty-nail dystrophy usually occurs sporadically but a few familial and hereditary cases have been reported. It has occasionally been described in association with ichthyosis vulgaris and atopic dermatitis, diffuse neuro-dermatitis, vitiligo, dark red lunulae and knuckle pads, selective immunoglobulin A (IgA) deficiency, autoimmune thrombocytopenic purpura and haemolytic anaemia.

Selective Immunoglobulin Deficiency

Figure 3.38

Trachyonychia—twenty-nail dystrophy of lichen planus.

Figure 3.38

Trachyonychia—twenty-nail dystrophy of lichen planus.

All these associations, however, should be considered coincidental.

Trachyonychia is typically associated with severe alopecia areata of children. According to the authors' data trachyonychia is observed in 12% of children and 3.3% of adults with alopecia areata. The frequency of this condition is closely related to the severity of the disease; it is more frequent in males than in females, with a male to female ratio of 4:1.

The onset and course of the nail changes are not strictly related to the onset and course of alopecia areata, and nail abnormalities in some patients may appear months or even years before the onset of hair loss. Some consider trachyonychia to be a negative prognostic factor for alopecia areata. It should, however, be noted that trachyonychia is typical of children with alopecia universalis who usually have a poor prognosis. When the outcome of treatment of alopecia areata is evaluated according to age and disease severity, the

Idiopathic tranchyonychia of childhood is a bening condition that usually returns entirely to normal presence or absence of trachyonychia is not important for the prognosis.

The frequency of idiopathic trachyonychia is unknown, although it is certainly rare, more commonly but not exclusively seen in children. Idiopathic trachyonychia may be a clinical manifestation of several nail diseases including lichen planus, psoriasis, eczema and pemphigus vulgaris. It may also represent a clinical variety of alopecia areata limited to the nails. Two clinical varieties of trachyonychia have been described: opaque trachyonychia (Figure 3.35) and shiny trachyonychia (Figure 3.33). Both these varieties may occur in association with alopecia areata or may be idiopathic. Opaque trachyonychia is more common than the shiny type.

In opaque trachyonychia the nail plate surface shows severe longitudinal ridging and is covered by multiple adherent small scales. The nail is thin, opaque, lustreless and gives the impression of having been sandpapered in a longitudinal direction (vertically striated sandpapered nails). The cuticle of the affected nails is ragged and some degree of koilonychia is often present. In shiny trachyonychia the nail plate surface abnormalities are less severe. Nail plate roughness is mild and caused by a myriad of minuscule punctate depressions, which give the nail plate surface a shiny appearance. In some patients a proportion of the nails have the sandpapered appearance while others have the shiny appearance. Trachyonychia is symptomless and patients complain of only brittleness and cosmetic discomfort.

Although trachyonychia is better known as twenty-nail dystrophy, the nail changes do not necessarily involve all nails in every patient (Figure 3.35). It is a symptom that may be caused by several inflammatory diseases that disturb nail matrix keratinization. There is no clinical criterion that enables one to distinguish spongiotic trachyonychia, the most common type, from trachyonychia due to other inflammatory skin diseases such as lichen planus, psoriasis, eczema or pemphigus vulgaris. Trachyonychia is a benign condition that never produces nail scarring. This is true not only for trachyonychia associated with spongiotic changes, but also for trachyonychia due to lichen planus or other dermatological disease. Spongiotic trachyonychia regresses spontaneously in a few years in most patients.

The association with vitiligo is a consequence of the frequent association of vitiligo with alopecia areata. Idiopathic trachyonychia can in fact be due to alopecia areata limited to the nails. This also explains why trachyonychia may occur in families and occasionally affects identical twins. The close link between trachyonychia

The only condition that is frequently associated with trachyoychia and should be searshed for in all cases is alopecia areata

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