Pediatric Trachyonychia- A Retrospective Study of 17 Cases

Dear Editor,

Trachyonychia is a chronic nail disorder characterized by rough, brittle, thin nails with excess longitudinal ridging.[1] Idiopathic trachyonychia does not show any other disease association while some cases are associated with dermatoses such as alopecia areata, lichen planus, and psoriasis.[2] It mostly affects children aged 3–12 years,[3] although cases occur across all ages. Topical therapy is preferred initially, while intralesional steroids and systemic therapy are reserved for severe or recalcitrant cases.[4] We conducted a retrospective study at a tertiary care hospital by evaluating case records, including clinical data, photographs, and treatment details, in pediatric trachyonychia patients between April 2017 and March 2019. The extent of improvement with therapy was graded as excellent (≥75% improvement); good (50%–75% improvement); moderate (25%–50% improvement) and minimal (<25% improvement).

Overall, 17 pediatric patients (12 males, 5 females) were clinically diagnosed with trachyonychia during the study period. The mean age at diagnosis was 8.2 ± 1.2 years (range: 5.4–12.5 years) with a mean duration of illness 29.2 ± 8.8 months (range: 9–47.5 months). All 20 nails were affected in 15 (88.2%) patients, with toenails more severely affected. While trachyonychia can have a familial basis,[4] no patient in our study had positive family history. (17.6%) and greyish-black (5.4%). Thirteen patients (76.4%) showed an associated comorbidity or dermatosis. While the literature mentions alopecia areata as a commonly associated dermatosis,[5] we found atopy to be the most common association in eight (47%) patients, of which two patients (11.7%) fulfilled diagnostic criteria for atopic eczema. Lichen planus and psoriasis were seen in two (11.7%) patients each and alopecia areata in only one patient. The most common color of trachyonychia was yellow (70.5%), followed by greyish-brown. Nail findings included longitudinal ridging (94%) [Figure 1], ragged cuticles (85%), coarse nail pitting (43%), splinter hemorrhages (31%), and onychoschizia (11%). Diagnosis in trachyonychia is primarily clinical and biopsy is not routinely indicated. When performed, histopathological examination shows spongiosis, hypergranulosis, and inflammatory cell exocytosis, which were indeed the reported findings in the only patient undergoing biopsy in our study.

Figure 1.

A patient with pediatric trachyonychia showing longitudinal ridging and yellowish discoloration of the affected nails

All patients in the study were asymptomatic and treatment was sought for cosmetic reasons. As per existing literature,[2] nail changes in trachyonychia are self-limited and tend to resolve with time, irrespective of therapy. However, we did not find spontaneous resolution in any case, even in those with a disease duration of >2–3 years. Initially, all patients received super-potent topical corticosteroids (clobetasol propionate 0.05%) and/or topical retinoids (tazarotene 0.1%). While literature suggests topical therapy to be ineffective owing to poor penetration of the drugs through proximal nail fold,[6] topical therapy was indeed effective, with 57% of patients showing excellent to good response. Systemic immunosuppressants are usually not needed in trachyonychia but can be employed in those with associated systemic conditions.[2] Systemic agents were added in 10/13 (77%) patients in our study for underlying dermatoses. Low-dose oral mini pulse (OMP) steroids with methotrexate were given in seven patients, while two patients received OMP alone and one patient received azathioprine. Patients receiving systemic therapy reported better subjective improvement and faster resolution of nail changes (excellent to good response in 70%) compared to the use of topical agents alone; however, the difference was statistically not significant (P = 0.58) owing to the small sample size. Mean time to achieve >50% response was 5.2 months (range: 3.2–9 months). On follow-up (mean: 12.5 months), three patients (17.6%) treated with topical agents had relapse (within 9 months) while no relapse was reported in those receiving systemic agents. Thus, our study characterized key demographic, clinical, and therapeutic trends in pediatric trachyonychia.

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Conflicts of interest

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