Tuesday, September 25, 2012

Alopecia Areata and Twenty Nail Distrophy

Abstract: 18 year old man with two year history of alopecia areata and six month history of dry lusterless nails.

HPI:  The patient is an 18 year-old college student who has had alopecia areata for the past 2 years.  He is well otherwise and has had no other problems until a number of months ago when he developed a nail dystrophy.   He takes no medications by mouth.  There is no family history of alopecia or autoimmune problems.  Treatment to date for alopecia has been intralesional triamcinlone with regrowth, however, new areas continue to evolve.

O/E:  There are 6 - 7 alopecic areas measuring from 2 to 6 cm in diameter widely scattered over the scalp.  He has some areas of alopepcia on his abdomen.
19 of his nails are dystrophic.  They are lusterless and many are greyish white in color, rough and friable.  One of his toenails appears normal

Clinical Photos:

Lab: All studies have been normal.  Records of these have been requested.

Diagnosis:  Alopecia areata and trachyonychia (aka 20 Nail Dystrophy)

Discussion and Questions: The patient has read about immunotherapy with DNCB and related chemicals.  Has anyone treated a patient with this modality who experienced long-lasting remission?  Do you know of good treatments for his nail dystrophy?

Alopecia universalis with twenty-nail dystrophy (trachyonychia).
Chien P Jr, Kovich OI.
Dermatol Online J. 2008 May 15;14(5):24.
Department of Dermatology, New York University, USA.
A 43-year-old man presented with long-standing trachyonychia of all 20 nails, which worsened after the onset of alopecia universalis 18 months ago. Trachyonychia can be associated with alopecia universalis although the treatment strategies of both conditions differ. The principle of treating trachyonychia may involve regulating the differentiation of keratinocytes and/or reducing inflammation in the nail fold or nail matrix while treatment of alopecia universalis involves immunomodulation.

Indian J Dermatol Venereol Leprol. 2011 Nov-Dec;77(6):640-5.
Trachyonychia: a comprehensive review.
Gordon KA, Vega JM, Tosti A.
Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida 33136, USA. kagordon@med.miami.edu
Trachyonychia or rough nails, may present as an idiopathic disorder of the nails or it can be associated with other dermatological conditions. The dystrophic nail findings seen in trachyonychia are characterized by brittle, thin nails, with excessive longitudinal ridging. The most common histopathologic features associated with trachyonychia are spongiosis and exocytosis of inflammatory cells into the nail epithelia; typical features of lichen planus or psoriasis can also be detected. Determining the cause of trachyonychia is challenging. Treatment is often unsatisfactory, although in general it should be aimed at the underlying cause, if found. In most cases, the nail abnormalities improve spontaneously.  Available full text

Vañó-Galván S, et. al. Sudden hair loss associated with trachyonychia. Cleve Clin J Med. 2008 Aug;75(8):567-8
Department of Dermatology, Ramón y Cajal Hospital, University of Alcalá, Madrid, Spain. sergiovano@yahoo.es  Free Full Text

Mandar Mane, Amiya Kumar Nath, and Devinder Mohan Thappa
Indian J Dermatol. 2011 Jul-Aug; 56(4): 407–411  F  Free Full Text

Twenty-nail dystrophy of alopecia areata.
Horn RT Jr, Odom RB.
Arch Dermatol. 1980 May;116(5):573-4
We describe here a patient with dystrophy of all 20 nails, which has persisted for five years after the resolution of alopecia areata. We feel that the term "20-nail dystrophy" is best used to describe a clinical entity that can have several causes.

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