Trachyonychia and Twenty-Nail Dystrophy: A Comprehensive Review and Discussion of Diagnostic Accuracy

Alopecia Areata of the Nails: Diagnosis and Management

Background: Alopecia areata (AA) is a common form of non-scarring alopecia characterized by acute hair loss. Nail involvement, though not always present, can occur in AA patients. Nail changes are more frequent in severe forms of AA and in children. Methods: Literature related to nail changes in AA was comprehensively reviewed after a search on the PubMed database without time restrictions in order to identify common clinical presentations and associated factors to aid clinicians with the correct evaluation and management of these dystrophies. Results: Nail changes in AA include pitting, trachyonychia, leukonychia, red lunula, and miscellaneous alterations such as longitudinal ridging and brittle nails. Nail changes are usually asymptomatic but, nevertheless, sometimes cosmetically disfiguring and can be associated with a reduced quality of life and impaired daily activities. Conclusions: Nail changes in AA may precede or follow hair loss and can occur as an isolated finding. Diagnosis may require a biopsy for definitive identification. Spontaneous improvement is possible, particularly in children, and treatment is not always necessary. Further research is, however, needed to establish a consensus on treatment approaches according to age and severity.

La trachyonychie de l’enfant: Aspects cliniques et évolutifs

INTRODUCTION

Trachyonychia means rough, longitudinally ridged nails with a sandy, brittle and thin aspect. It is a rare condition that occurs mainly in children. Studies on trachyonychia are rare. We aimed to describe the clinical aspects and outcome of trachyonychia, as well as its treatment.

CASES

Two boys aged 11 and 14 years old and a girl aged 6 years presented with nail dystrophy of the fingers and toes. Patient 1 had also a scaly patch on the glans penis, and patient 2 was atopic. Trachyonychia associated with psoriasis was suspected in patient 1 and the idiopathic form was retained in the other two patients. All patients were treated with topical steroids for a few months. The patients did not show any improvement at the six-month follow-up. Only one patient was contacted again after two years and showed spontaneous healing.

COMMENTARIES

The diagnosis of trachyonychia is mainly clinical. In the literature, 62% of pediatric patients had an idiopathic form. However, a strong association was observed between trachyonychia and alopecia areata. Trachyonychia of childhood appears to have a good prognosis, with spontaneous improvement within six months to two years. Therapeutic abstention is the rule.

Efficacy of Fluocinonide\Bifonazole Cream for the Treatment of Trachyonychia: A Retrospective Case Series

Background

Trachyonychia is a benign nail condition, most commonly seen in children. Trachyonychia manifests as excessive longitudinal ridging, nail roughness, and nail brittleness. Treatment is sought mainly for esthetic reasons as well as functional reasons. A number of therapeutic approaches exist, mainly based on case reports or small non-comparative case series.

Aims

To report treatment outcome among patients with trachyonychia.

Methods

A retrospective case-series study was conducted among patients who were treated trachyonychia between years 2017 and 2020. Patients were prescribed fluocinonide 0.05% with bifonazole 1% cream, applied with or without occlusion, and methylprednisolone 1-2 mg/nail, injected into the involved nail matrix, or oral cyclosporine 3 mg/kg. Complete response (over 90% improvement) and partial response (over 50% improvement) were assessed.

Results

A total of 43 patients with trachyonychia were included [mean age 10.0 years (±5.7), 69.8% males, mean disease duration 4.7 years (±3.0)]. In 90.7% of the cases, topical fluocinonide\bifonazole cream was prescribed. Under-occlusion topical application was found to be highly effective, achieving complete response in 35.3% and partial response in an additional 52.9% of the patients. Occluded application was also found to be significantly more effective than non-occluded application. Treatment efficacy was not affected by the severity of nail roughness, trachyonychia morphology, or whether trachyonychia was idiopathic or coexisted with other dermatological conditions.

Conclusion

Occluded application of fluocinonide plus bifonazole cream is efficient for the treatment of trachyonychia and should be considered a first line of treatment.

Recovery of Alopecia Universalis with Associated Nail Dystrophy Treated with Tofacitinib: A 6-year-old Child's Case Report

An emerging treatment modality whose established efficacy in systemic inflammatory diseases is now being actively explored for cutaneous disorders: tofacitinib, an oral Janus kinase inhibitor, is one such treatment. Alopecia universalis has been reported to improve with the use of tofacitinib in various case reports and case series. Nail dystrophy is a diverse skin disorder that has been linked to autoimmune illnesses such as psoriasis and psoriatic arthritis in certain subtypes. Alopecia areata and alopecia universalis are also commonly associated with nail dystrophy. In the present case report, we see that there are also improvements in nail dystrophy in the patient with alopecia universalis who is using tofacitinib.

Diagnosis of Onychomycosis: From Conventional Techniques and Dermoscopy to Artificial Intelligence

Onychomycosis is a common fungal nail infection. Accurate diagnosis is critical as onychomycosis is transmissible between humans and impacts patients' quality of life. Combining clinical examination with mycological testing ensures accurate diagnosis. Conventional diagnostic techniques, including potassium hydroxide testing, fungal culture and histopathology of nail clippings, detect fungal species within nails. New diagnostic tools have been developed recently which either improve detection of onychomycosis clinically, including dermoscopy, reflectance confocal microscopy and artificial intelligence, or mycologically, such as molecular assays. Dermoscopy is cost-effective and non-invasive, allowing clinicians to discern microscopic features of onychomycosis and fungal melanonychia. Reflectance confocal microscopy enables clinicians to observe bright filamentous septate hyphae at near histologic resolution by the bedside. Artificial intelligence may prompt patients to seek further assessment for nails that are suspicious for onychomycosis. This review evaluates the current landscape of diagnostic techniques for onychomycosis.

Histopathologic findings of idiopathic trachyonychia: An analysis of 30 adult patients

BACKGROUND

Trachyonychia, a rare inflammatory disease of the nail matrix, has a more chronic course in adults compared with that in children. However, the histopathologic features of the disease have not been sufficiently reported in the literature.

METHODS

We retrospectively reviewed the pathologic features of idiopathic trachyonychia in adult cases at our center.

RESULTS

A total of 30 cases were included. The median age was 55.5 years (range, 27-77 years). Median disease duration was 84 months (range, 8-384 months). Histopathologic analysis showed upper dermal lymphocytic infiltrates (93.3%), acanthosis (86.7%), exocytosis (63.3%), spongiosis (63.3%), parakeratosis (46.7%), psoriasiform hyperplasia (40%), eosinophilic infiltrates (33.3%), vacuolar degeneration (33.3%), lichenoid pattern (13.3%), Civatte body (6.7%), and collection of neutrophils in the stratum corneum (3.3%). Statistical analysis among pathologic parameters revealed associations of spongiosis with exocytosis (P < 0.001) and lichenoid infiltration with vacuolar degeneration (P = 0.008). Three patients (10%) showed fungal co-infection.

CONCLUSION

The majority of cases revealed inflammatory cell infiltration with epidermal changes. Given the inflammation and chronic course of idiopathic trachyonychia in adulthood, active treatment with anti-inflammatory agents should be considered. Additionally, mycological tests should be considered during initial evaluation as there are cases with fungal coinfection.

Twenty-Nail-Dystrophy / Trachyonychia: a case report in a five year old girl seen at the Paediatric Out-patient Department of a Tertiary Hospital in Lafia North-Central Nigeria

Twenty-Nail-Dystrophy (TND) also referred to as Trachyonychia is a disorder of the nails. It can affect all the nails hence the name. Trachyonychia is characterized by nail roughness, longitudinal ridging, fragility and hyper-pigmentation. It can occur in all ages and respond poorly to treatment. With this background, we report the case of a five year old girl with this disorder.

Treatment of idiopathic onychodystrophy with a 1064 nm picosecond neodymium-doped:yttrium aluminum garnet laser: A retrospective study

BACKGROUND

Laser treatment has emerged as a novel treatment modality for onychodystrophy. Only a few small series have assessed the efficacy of laser treatment in onychodystrophy, most of which were case reports. The therapeutic effect of the 1064 nm neodymium-doped:yttrium aluminum garnet (Nd:YAG) laser for onychodystrophy has been demonstrated. Recently, the picosecond Nd:YAG (PSNY) laser has been introduced to improve various skin disorders.

AIMS

The aim of this study was to verify the efficacy of a 1064 nm PSNY in management of idiopathic onychodystrophy.

METHODS

We present a case series of dystrophic nails treated with a PSNY for onychodystrophy improvement. Planimetry using ImageJ software was used to calculate lesion reduction and proximal clear nail growth. Clinical improvement was assessed using a 5-point Global Assessment Scale (GAS). Adverse events were also assessed.

RESULTS

Twenty-five patients (11 males and 14 females) with a total of 128 nails (94 finger nails and 34 toe nails) were treated. The mean treatment number was 8.7 ± 6.2, and the mean total duration of treatment was 33.4 ± 34.6 weeks. The average proportion of the lesion area decreased significantly (from 65.9% to 46.6%) after PSNY treatment (P < .001). The mean GAS (3.16 ± 1.18) exhibited fair improvement, and there were no serious adverse events.

CONCLUSION

The 1064 nm PSNY laser can provide fair improvement for onychodystrophy with a good prognosis at least during the follow-up period and optimal cosmetic results in Asian patients.

Trachyonychia: a retrospective study of 122 patients in a period of 30 years

BACKGROUND

Trachyonychia is a nail disease characterized by longitudinal striations, ridges, fissures and/or pitting. This condition can be both idiopathic and associated with other dermatologic diseases.

OBJECTIVE AND METHODS

The aim of this retrospective study was to analyse the clinical features, onychoscopy, therapy efficacy and outcome of 122 patients with trachyonychia visited at the Hair Disease Outpatient Consultations of the Dermatology Unit of the Department of Experimental, Diagnostic and Specialty Medicine of the University of Bologna, from 1988 to 2018.

RESULTS

Opaque trachyonychia was the most observed type while shiny trachyonychia, less common, was present especially in milder cases. Pitting was the most frequently observed feature (80.3%), followed by koilonychia (45%) and hyperkeratosis (19.6%). Nail matrix longitudinal biopsy was performed for diagnosis confirmation in 29 cases, and spongiotic was the most common pattern. Topical therapy was prescribed in 109 patients while systemic treatments were reserved for severe cases (38 patients); 22 patients did not receive any treatment. A marked improvement in the appearance of the nails or even a total resolution was seen in 63 patients.

CONCLUSIONS

Trachyonychia can occur at any age but is more frequent in children and often associated with alopecia areata. The pathological diagnosis of trachyonychia is not mandatory as the disease has generally a benign outcome. Considering the absence of pain and the high rate of spontaneous resolution, treatment is often prescribed only for cosmetic reasons or reserved for severe cases.