Trachyonychia treated with oral mini pulse therapy

Introduction

Twenty nail dystrophy or trachyonychia is considered as an isolated defect or as a physical sign that may be seen in association with diseases such as lichen planus, alopecia areata and onychomycosis. It occurs most commonly but not exclusively in childhood and may become less obvious with age. Usually all the twenty nails are affected, however there may be sparing of one or more nails. The treatment of trachyonychia is unsatisfactory. We report a 12-year-old girl with trachyonychia treated successfully with oral mini-pulse therapy with betamethasone.

Case Report

A 12-year-old girl developed discolouration and roughening of finger and toenails simultaneously at the age of 8 years. Over the next four years, the nail dystrophy gradually increased. There was sparing of lateral two toes of the right foot and the second and fourth toe of left foot. At the time of presentation to us, the affected nails were dull, opalescent with brown to black irregular discolouration and roughened surface. There was superficial pitting, mild subungual hyperkeratosis and irregular longitudinal ridging. The patient did not agree for biopsy of the nail. Repeated KOH smear of nail scraping for dermatophytes was negative. Routine baseline investigations such as haemogram, renal and liver function tests,chest X-ray, urinalysis and examination of stool were within normal limits.

After explaining the nature of the condition, the unpredictable natural course of the disease and lack of any definitive well accepted treatment modality, we decided to treat the patient with systemic corticosteroids in the form of oral mini-pluse (OMP) therapy. It consisted of 4mg of betamethasone as a single oral dose with breakfast on two consecutive days every week and no treatment on the remaining 5 days of the week. In two months, there was growth of normal looking healthy nails in proximal one-third of the nails and there was clearance of the abnormal nail changes in six months. There were no side effects of OMP.

Discussion

Trachyonychia, derived from the Greek word ′trakos′ meaning rough, describes the broad spectrum of nail changes that occur in twenty nail dystrophy.[1] It may be idiopathic or can occur in several conditions like alopecia areata, lichen planus[2] and also in onychomycosis. The idiopathic type begins insidiously in early chilhood. All twenty nails are uniformly affected with excessive longitudinal striations, roughening of nail plate with loss of nail lustre.[3] This is believed to be a self limiting condition that may resolve slowly with age. Familial severe twenty nail dystrophy is described as dystrophic changes in the nails present at birth and tending to be persistent.[4] In some patients, all the twenty nails may not be affected and one or a few may be spared.

Treatment of trachyonychia is unsatisfactory and usually unrewarding. Various modalities of treatment have been tried-viz, griseofulvin, systemic, topical and intralesional corticosteroids[5], but they have been found largely unsuccessful. We treated our patient with corticosteroids with the oral minipulse schedule. OMP has been used as 5 mg beta methasone/dexamethasone as a single dose on two consecutive days every week for an average adult in conditions like fast-spreading vitiligo.[6] The main advantage of this form of therapy is that the patient usually does not develop significant side effects generally seen with the daily dose of corticosteroids over some weeks or months. OMP may prove to be a safe and effective treatment modality for trachyonychia as in our patient.