Severe onycholysis in a card illusionist with alopecia areata universalis.

In patients with alopecia areata (AA), nail abnormalities due to nail matrix inflammation are common and usually not severe. We report the case of a 23-year-old man with AA universalis, who developed severe abnormalities of all his fingernails. Systemic steroids improved the onycholysis that had an important impact on the patient's job, as he was a card illusionist.

INTRODUCTION

The fingernails are useful “tools” in many occupations. Nail fragility, nail thickening and onycholysis may considerably reduce ability to manipulate small objects and can be a serious handicap, for example, to jewelers, musicians or… illusionists.

CASE REPORT

We report the case of Mario, an eccentric 23-year-old man, a card illusionist who had alopecia areata (AA) universalis for the last 15 years. He had accepted his hair loss and was not seeking treatment for it. In January 2007, he consulted us because he developed severe abnormalities of all his fingernails.

At clinical examination, the fingernails were yellow – gray colored and showed severe onycholysis, involving the whole nail plate and nail bed hyperkeratosis [Figure 1]. The patient asked for treatment as the nail changes did not permit him to continue his work as card illusionist. He was treated with intramuscolar triamcinolone acetonide 0.5 mg/kg/month, for 3 months [Figure 2]. The nails improved rapidly with complete return to normality after 6 months. However, the 1-year follow-up revealed mild recurrence of nail symptoms.

Figure 1

Severe onycholysis with distal to proximal detachment of the nail plate, nail bed hyperkeratosis

Figure 2

Regression of the nail changes after systemic triamcinolone acetonide for 3 months

DISCUSSION

AA is a relatively common inflammatory form of non-scarring hair loss. AA most commonly affects the scalp but it may involve beard, eyelashes, eyebrows, pubic, axillary, body hair.[123] In patients with AA, nail abnormalities were found in 10-66% of the patients.[4] Hence, nail changes due to nail matrix inflammation are common and usually not severe; geometric pitting affects up to 34% of patients, others alterations include trachyonychia, punctate leukonychia, mottled lunulae and onychomadesis.[123] The nail involvement tend to regress spontaneously over the years.[123] Severe nail abnormalities are uncommon and in our experience improve with systemic steroids.

The nails are useful “tools” in many occupations and their cosmetic appearance is important in all occupations where personal contact occurs.[5]

In Mario's case the nail abnormalities were severe and affected the nail bed with symptoms that are not typical of nail AA. Systemic steroids were very effective and treatment was justified by the important impact of the nail changes on the patient's job.