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 Table of Contents  
Year : 2020  |  Volume : 22  |  Issue : 1  |  Page : 84-86

Twenty nail onychomadesis following acute viral hepatitis B infection

1 Department of Dermatology, Military Hospital Jodhpur, Jodhpur, Rajasthan, India
2 Department of Dermatology, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission07-Aug-2019
Date of Decision02-Oct-2019
Date of Acceptance10-Oct-2019
Date of Web Publication03-Mar-2020

Correspondence Address:
Maj M Sivasankari
Department of Dermatology, Military Hospital Jodhpur, Jodhpur - 342 001, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_46_19

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Onychomadesis is a nail plate abnormality with temporary cessation in the growth of the nail plate due to disturbances in the nail matrix. Any local or systemic condition affecting the nail matrix directly or indirectly can lead to onychomadesis. The causes can vary from idiopathic infections to systemic causes. Although onychomadesis is not a finding unique to any disease, it indicates the presence of a preceding trigger, which affects the nail matrix. Here, we report one such case of onychomadesis following acute hepatitis B infection.

Keywords: HBV, hepatitis, onychomadesis

How to cite this article:
Sivasankari M, Sinha P. Twenty nail onychomadesis following acute viral hepatitis B infection. J Mar Med Soc 2020;22:84-6

How to cite this URL:
Sivasankari M, Sinha P. Twenty nail onychomadesis following acute viral hepatitis B infection. J Mar Med Soc [serial online] 2020 [cited 2021 Oct 21];22:84-6. Available from: https://www.marinemedicalsociety.in/text.asp?2020/22/1/84/279882

  Introduction Top

Onychomadesis is a noninflammatory condition involving the separation of the nail plate from the nail matrix.[1],[2] It is the temporary stoppage of nail growth due to the involvement of the matrix. The presentation can vary from Beau's lines to onycholysis.[2] The causes of onychomadesis can be numerous like trauma and dermatological diseases such as eczema, paronychia, systemic conditions, viral illness, drugs, Kawasaki disease, and peripheral ischemia.[3],[4],[5],[6],[7],[8],[9] Hepatitis B as a cause of onychomadesis does not find a mention in the literature. Here, we report one such rare case.

  Case Report Top

A 23-year-old male presented with complaints of changes in both the finger and toenails in the form of painless and palpable splits of the nail plates for the past 2 weeks [Figure 1] and [Figure 2]. He was otherwise asymptomatic. He had presented with fever, vomiting, and jaundice 7 weeks back, following which he was admitted and investigated. He was found to be serologically positive for hepatitis B infection (anti-HBsAg and anti-HBeAg Ab) and had elevated liver function tests. He was managed symptomatically with rest, adequate fluid intake, good nutrition including carbohydrate-rich food and antihistamines. He was symptomatically better by 3rd week, and his liver function tests were normal by 5th week. The patient denied any history of recent trauma, drug intake, other previous skin conditions, or exposure to chemicals.
Figure 1: Onychomadesis of the fingernails

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Figure 2: Onychomadesis of the fingernails (left hand)

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Clinical examination revealed horizontal grooves with onychoschizia proximal to the groove, equidistant from the proximal nail fold in all the fingernails and toenails [Figure 1], [Figure 3] and [Figure 4]. The nail folds were normal. Routine serum biochemistry and hematology results were normal. Nail clippings were negative for fungal elements. A diagnosis of onychomadesis in all the finger and toenails was made. The onset of nail changes in the patient started 5 weeks after acute viral hepatitis. Hence, we assume that the HBV infection must have triggered the process of nail matrix arrest.
Figure 3: Onychomadesis of the toenails (left)

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Figure 4: Onychomadesis of the toenails (right)

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  Discussion Top

Onychomadesis is a condition of the nail, in which there is a separation of the nail plate from the nail bed. The exact pathophysiology is not known.[1] It is contemplated that there is arrest of nail matrix growth or change in the quality of the nail plate which leads to thinning and splitting of the nails. The insult to the nail matrix can be a systemic or local cause. Later, once the nail matrix recovers from the insult, there is reproduction of the nail plate. Onychomadesis may be considered as the severe variant of Beau's lines, which are seen as horizontal ridges over the nail plates. Onychomadesis leads to complete separation which in few cases, maybe followed by shedding of the nail plate. While the Beau's lines present as thin nail plate with transverse grooves due to the slowing or cessation in proximal nail matrix growth, onychomadesis presents as separation from the plate due to a complete halt in the matrix growth.[2]

The process of onychomadesis usually starts in the proximal part of nail. The causes of onychomadesis may be idiopathic or secondary to various conditions. The conditions predisposing to onychomadesis can be trauma, local nail infections, systemic disorders (Kawasaki disease, Stevens–Johnson syndrome, autoimmune diseases, and pemphigus vulgaris), drugs (chemotherapeutic agents and valproic acid[3],[4]), and infections.[2] The various infections which may lead to onychomadesis are diphtheria, hand–foot–mouth disease, mumps, varicella infection, syphilis, malaria, measles, scarlet fever, enteric fever, and dermatophytosis due to Trichophyton tonsurans. Onychomadesis due to trauma or nail matrix infection usually occurs in few nails, in which the nail matrix is directly/indirectly affected.

The nail changes are self-limited. Hence, there is no active management. The underlying etiology should be searched for and treated. Supportive management in the case of viral infections or discontinuation of a causative drug helps in the recovery of the nail from the insult.[5] Conservative management in the form of protection of the nail bed by maintaining short nails and the use of adhesive tapes on the damaged nails have been recommended. Few modalities of treatment including occlusive dressing using keratolytics or topical steroids have been tried but proved less efficacious. Reassurance and counseling of the patients form the main part of management.

So far, onychomadesis following viral infections such as hand–foot–mouth disease (Coxsackie B), measles, and varicella has been reported in the literature.[6],[7],[8],[9] Onychomadesis due to scarlet fever also has been noted. Nail changes in liver disease patients have been studied previously which showed that onychomycosis, onycholysis or brittle nails and longitudinal striations were commonly seen with HBV infection.[10],[11] Leukonychia and Terry's nails have been reported in patients with hepatitis infection.[10] Association of onychomadesis with hepatitis B virus has not been reported so far.

Our case, in which all the twenty nails had onychomadesis is being reported to bring to light the role of hepatitis B viruses as one of the causes of onychomadesis. To the best of our knowledge, our case is the first reported case of onychomadesis, which has involvement of all the twenty nails following acute hepatitis B infection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Chu DH, Rubin AI. Diagnosis and management of nail disorders in children. Pediatr Clin North Am 2014;61:293-308.  Back to cited text no. 1
Braswell MA, Daniel CR 3rd, Brodell RT. Beau lines, onychomadesis, and retronychia: A unifying hypothesis. J Am Acad Dermatol 2015;73:849-55.  Back to cited text no. 2
Piraccini BM, Iorizzo M, Antonucci A, Tosti A. Drug-induced nail abnormalities. Expert Opin Drug Saf 2004;3:57-65.  Back to cited text no. 3
Poretti A, Lips U, Belvedere M, Schmitt B. Onychomadesis: A rare side-effect of valproic acid medication? Pediatr Dermatol 2009;26:749-50.  Back to cited text no. 4
Salgado F, Handler MZ, Schwartz RA. Shedding light on onychomadesis. Cutis 2017;99:33-6.  Back to cited text no. 5
Nag SS, Dutta A, Mandal RK. Delayed cutaneous findings of hand, foot, and mouth disease. Indian Pediatr 2016;53:42-4.  Back to cited text no. 6
Tan ZH, Koh MJ. Nail shedding following hand, foot and mouth disease. Arch Dis Child 2013;98:665.  Back to cited text no. 7
Wei SH, Huang YP, Liu MC, Tsou TP, Lin HC, Lin TL, et al. An outbreak of coxsackievirus A6 hand, foot, and mouth disease associated with onychomadesis in Taiwan, 2010. BMC Infect Dis 2011;11:346.  Back to cited text no. 8
Podder I, Das A, Gharami RC. Onychomadesis following varicella infection: Is it a mere co-incidence? Indian J Dermatol 2015;60:626-7.  Back to cited text no. 9
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Salem A, Gamil H, Hamed M, Galal S. Nail changes in patients with liver disease. J Eur Acad Dermatol Venereol 2010;24:649-54.  Back to cited text no. 10
Godara SK, Thappa DM, Pottakkatt B, Hamide A, Barath J, Munisamy M, et al. Cutaneous manifestations in disorders of hepatobiliary system. Indian Dermatol Online J 2017;8:9-15.  Back to cited text no. 11
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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