Wednesday, February 20, 2013

Transverse Leukonychia

Dr. Richard Ratzan, an Emergency Room physician in Connecticut, recently saw an institutionalized bipolar woman in her 50s for another problem and noted a distinctive nail dystrophy.  It looks like transverse leukonychia of which there are only a few references in the literature.  The woman has a history of biting but no significant medical history that he is aware of.  We don't know if she's had electroshock therapy or intermittent chemotherapy that may have been contributory.  Could some type of self-induced trauma have caused this?

Dr. Ratzan writes us: "Although i am not a dermatologist, i have long been interested in physical diagnosis and especially nails. i usually take a good look at my patients' nails. What struck me as interesting in this man was the following: i had never seen this pattern before; i could not and still can not imagine a pathophysiological process leading to such an unusual symmetrical pattern of feathered chevrons that were non-continuous across the longitudinal midline of the nail; and lastly, from a strictly aesthetic point of view, i find them almost weirdly beautiful!"

Discussion:  Transverse Leukonychia have been reported a number of times in the medical literature but most cases have been associated with combined chemotherapy or some other pharmacologic agents.  Reference # 3 is interesting but there is no abstract and the source is difficult to find.  Does anyone have access to this?  Muehrcke Lines and Mee's lines would appear to be different entities often confused with this type of transverse leukonychia.  Or, perhaps we are missing something inthis woman's history.

1. Arch Dermatol. 1983 Apr;119(4):334-5.  Chemotherapy-induced transverse white lines in the fingernails.  James WD, Odom RB.  (A good review, but no abstract – only useful for those with access to Archive of Derm)
2.  CMAJ. 2012 Aug 27.  Muehrcke lines  Sharma V, Kumar V. (Shows why our patient does not have this.)
3.  Traumatic transverse leukonychia.  Maino KL, Stashower ME.  Skinmed. 2004 Jan-Feb;3(1):53-5. No abstract available.


  1. Dr Vijay ZawarFebruary 24, 2013

    Just a random thought... please get the Arsenic estimation in this patient and also of the drinking water in the viscinity of the patient.

    BTW, Is there any chance of history of suicidal attempts in last 6 months to one year?

  2. from Robert Shapiro, Hili, Hawaii: I don't think a systemic cause can cause a white nail line that's interrupted and not a straight line and also different line on different nails. A systemic effect should be the same on all nails."

  3. from Ashok Kumar Sharma. "The clinical entity purely from morphology is 'Transverse leukonychia'. Now the probable causes have been enumerated by the reporting author. Many patients present out of concern for these white spots. Important is to reassure them about this manifestation. I have seen transverse leukonychia in apparently normal people also."

  4. from Prof. Dr. Eckart Haneke (Germany): "The white lines are mostly very regular in their arrangement and they are confined to one or both sides of the nails. This is highly unlikely to be of self-injurious cause. On the other hand, a systemic event should cause lines reaching from one side to the other. Baran claimed that subungual proximal onychomycosis may cause repeated white transverse lines."

  5. Striate leukonychia (true leukonychia) can be considered. It is commonly observed in the fingernails of women and the cuase can be matrix trauma secondary to manicures. Also it looks like nail abnormalities are mostly limited to the first three digits. Does she have any hx of carpal tunnel syndrome? Peripheral neuropathies could also cause nail changes per literature. Thank you for presenting the patient's case.

  6. from R. Baran: "
    Transverse leuconychia may be genetic, traumatic or systemic.
    The picture of the case you sent me is genetic.
    May I suggest you to get my book: “Nail diseases and their management” 4th ed (2012) Wiley-Blackwell.
    Robert BARAN, MD
    Honorary Professor of the University of Franche-Comté
    Nail Disease Centre - 42, rue des Serbes - 06400 CANNES (France)

  7. from Mary Maloney, U Mass Dept. of Dermatology: "It must represent trauma of some nature. If all the lines were at the same location from the growing nail plate, you could think ECT etc, but they are all staggered."


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