Friday, 15 August 2014

Shiny trachyonychia

Trachyonychia (Gk trachys rough, onychos nail) presents as a rough surface affecting the entire nail plate in up to 20 nails. Thus trachyonychia may involve one, several or all digits and when most or all digits are involved, the term twenty-nail dystrophy is commonly used. Trachyonychia may affect patients from all age groups although it is most commonly diagnosed in children. Familial forms exist. Spontaneous resolution might occur.

Based on appearance, trachyonychia is divided into two types*: (1) Opaque trachyonychia where nail is ridged and rough, and is deprived of its natural lustre. The nail appears sandpapered in a longitudinal direction (severe trachyonychia). (2) Shiny trachyonychia where the nail plate is shiny with numerous, closely aggregated, small superficial pits. This shiny appearance may be accentuated by a camera flash or by tangential light from a pen-torch (mild trachyonychia). The severity of trachyonychia frequently varies from nail to nail and the shiny and opaque varieties of the disease may coexist in the same patient.

The most common presentation is as an isolated nail abnormality (idiopathic) where histopathology shows spongiosis and a lymphocytic infiltrate of the nail matrix. It can be associated with psoriasis (pitting of the fingernails may be the only manifestation for months or even years), alopecia areata, lichen planus (it may be its sole manifestation and some regard nail lichen planus as a distinct condition) and other conditions. Unilateral involvement may occur in complex regional pain syndrome. Localized trachyonychia in a judo player** from the repeated grabbing of opponents’ uniforms has been described. Routine biopsy is not recommended.

Treatment is often useless and several forms have been suggested. Tazarotene alone or in association with topical steroids may improve the condition. The safety of tazarotene has not been established in patients under the age of 18 years.

Shiny trachyonychia affecting all the fingernails 

*Baran RDuprè AChristol BBonafe JLSayag JFerrere JL'ongle grèsè peladique. Ann Dermatol Venereol 1978105:387392.

**Shelley WBShelley DE‘Judo’ nailsCutis 199556912.

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Main Works of Reference List (The first eight are my top favourites)

  • British National Formulary
  • British National Formulary for Children
  • Guidelines (BAD - BASHH - BHIVA - Uroweb)
  • Oxford Handbook of Genitourinary Medicine, HIV, and Sexual Health
  • Oxford Handbook of Medical Dermatology
  • Rook's Textbook of Dermatology
  • Simple Skin Surgery
  • Weedon's Skin Pathology
  • A Concise Atlas of Dermatopathology (P Mckee)
  • Andrews' Diseases of the Skin
  • Andrology (Nieschlag E FRCP, Behre M and Nieschlag S)
  • Bailey and Love's Short Practice of Surgery
  • Davidson's Essentials of Medicine
  • Davidson's Principles and Practice of Medicine
  • Fitzpatrick's Colour Atlas and Synopsis of Clinical Dermatology (Klaus Wolff FRCP and Richard Allen Johnson)
  • Fitzpatrick’s Dermatology in General Medicine
  • Ganong's Review of Medical Physiology
  • Gray's Anatomy
  • Hamilton Bailey's Demonstrations of Physical Signs in Clinical Surgery
  • Hutchison's Clinical Methods
  • Lever's Histopathology of the Skin
  • Lever's Histopathology of the Skin (Atlas and Synopsis)
  • Macleod's Clinical Examination
  • Martindale: The Complete Drug Reference
  • Oxford Handbook of Clinical Examination and Practical Skills
  • Oxford Textbook of Medicine
  • Practical Dermatopathology (R Rapini)
  • Sexually Transmitted Diseases (Holmes K et al)
  • Statistics in Clinical Practice (D Coggon FRCP)
  • Stockley's Drug Interactions
  • Treatment of Skin Disease: Comprehensive Therapeutic Strategies
  • Yen & Jaffe's Reproductive Endocrinology