Thursday, October 20, 2005

Atypical Nail Pits

Case for Discussion:
This 40 year-old woman presented for evaluation of a nail dystrophy present for 2-3 months.
She has a history of Hashimoto's thyroiditis. About 9 months ago she developed vitiligo.
Her health is otherwise normal
Meds. Synthyroid and iron
Lab: Thyroid Perox AB 248 (Nl. 0 - 34 IU/ML)
ANA < 1:40

Physical Exam:
Vitiligenous patches left neck and left upper back
Around 4 finger nails show a distinctive pitting. The pits are fairly uniform and the affected nails are rough and lusterless. There are no cutansous lesions of psoriasis.

Discussion and Questikon:
The picture is atypical for psoriatic nail pits but that is not excluded.
I favor a relationship to the underlying autoimmunity that has caused the Hashimoto's and vitiligo.
The picture is similar to that seen with alopecia areata, but the patient has not has any alopecic patches.
Nail dystrophy has occasionally been described before the development of A. areata. And patients with Hashimoto's thyroiditis have a higher than expected incidence of alopecia areata.
We welcome your thoughts or suggestions.


  1. This is an unusual presentation of nail pitting. They may precede cutaneous manifestations. We know that nail pitting can be seen in psoriasis, lichen planus, alopecia areata, atopic dermatitis and occasionally unknown cause. Perhaps this case may illustrate to us the association of the auto immune clusters - diabetes, vitiligo, hashimoto's thyroiditis, alopecia areata and nail pitting. Time will unmask the true association in this patient.

  2. Ben Barankin, MDNovember 01, 2005

    I'd forewarn her that she may develop patches of alopecia areata in the ensuing months. I think
    like the herald patch of pityriasis rosea, we are observing the herald nails of impending alopecia areata.

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