Single Digit Leuconycia

The patient is a 64 yo school teacher who presents for a white nail.

Anamnesis: "The nail has been white for at least 6 months.  No other fingernails or toenails are white.  I had a ring on that finger that got super tight. I have finally removed the ring.  Sometimes the finger hurts, even now, like it may be arthritic."

The patient's questions are:

Is there something I can do to get it back to being a normal color?

Will it ever go back on its own to being normal - no longer white?

O/E:  The nail of the 4th finger of the left hand is uniformly white.  There is no flaking or friability.  Other than the color, the nail plate looks normal. All other finger- and toenails are normal

Photo:

Diagnosis:  Ring finger Leuconycia totalis.  This does not look like superficial white onycholysis.  At the time I saw the patient, I did not think to do a KOK prep since the nail plate looked so normal.

Thoughts: Single-digit leuconychia totalis has not been reported in the medical literature.  It is likely that prolonged ischemia may have played a role.
Dr. Eckart Haneke's comments were helpful: "Single digit leukonychia is just a description of the condition, not a diagnosis. I think this is due to the long-term poor blood supply of the finger. There is no similarity to superficial white onychomycosis. I cannot predict the future development. It may get slowly better, but this will take some more time. If you want to know something more about the situation you need a comparative demonstration of the blood circulation, e.g. by thermography or another similar method, of this and the contralateral finger. Diffuse leukonychia is sometimes seen in Raynaud's and other disturbances of blood supply."

Reference:
Leuconychia in reflex sympathetic dystrophy:
a chance association? Vanhooteghem O, et.al.
Br J Dermatol. 1998 Aug;139(2):355-6.
PDF of reference.

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.

References:

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.