ARTICLE
In February 1997, a 40-year-old housewife was referred to our Department
for a nail dystrophy that involved all ten fingers and had been present
for two years.
The clinical examination revealed longitudinal grooving, ridging, splitting,
thinning, brown discolouration and linear depressions of the nail plate.
This was associated with nail fragility and marked inflammation of the
proximal nail folds which were erythematous.
The skin of the fingertips showed a honeycomb appearance due to multiple,
small, punctate, hyperkeratotic depressions.
The patient complained of itching, stinging sensation, burning and pain
in the fingertips.
She complained of exacerbation of lesions during the winter. Examination
of the skin, hair and mucous membranes were negative.
The patient did not report any stressful situation before the onset
of her disease. Her history was negative for diabetes, hepatitis, hypertension
and intake of systemic medications.
Potassium hydroxide preparations and cultures of nail scrapings gave
negative results.
Routine biochemical and haematological investigations were normal.
Lichen planus of the nails
and fingertips
A longitudinal biopsy specimen of the fifth right finger nail showed
a bandlike, lymphocytic infiltrate, with activity at the dermal-epidermal
interface underlying the ventral portion of the proximal nail fold, the
matrix, the nail bed and the hyponychium.
A skin biopsy from a pulp lesion was also diagnostic
for lichen planus.
Capillaroscopy of the proximal nail fold showed mild capillary dilations.
Intramuscular triamcinolone acetonide, 40 mg per month, for 4 months
produced regression of the disease.
Comments
Lichen planus is a dermatological disease that most commonly affects
middle-aged adults.
It can involve skin, mucous membranes, hair and nails.
Nail lichen planus may occur in the absence of skin lesions [1-7], but,
to our knowledge, there are no cases in the literature of nail lichen
planus associated with fingertip involvement.
Ulcerative lichen planus may affect the palms
and soles where the disease produces chronic bullae or severe erosions
which tend to heal with residual atrophy [8-10].
The lesions of our patient, however, manifested clinical features different
from the above: the numerous punctate depressions resembling punctate
keratoderma.
Differential diagnoses of nail and fingertip diseases include punctate
keratoderma, allergic contact dermatitis, psoriatic lesions, onychomycosis,
lichen nitidus, twenty-nail dystrophy and secondary syphilis.
Without examination of a nail biopsy specimen, this case would not have
been diagnosed as lichen planus.
REFERENCES
1. Tosti A, De Padova MP, Taffurelli M, et al. Lichen planus limited
to the nails. Cutis 1987; 39: 481-2.
2. Kanwar AJ, Govil DC, Singh OP. Lichen planus limited to the nails.
Cutis 1983; 32: 163-8.
3. Burgoon CF, Kostrzewa RM. Lichen planus limited to the nails. Arch
Dermatol 1969; 100: 371.
4. Bhargava RK, Goyal RK. Solitary involvement of the nails in lichen
planus. Indian J Dermatol 1975; 41: 142.
5. Scott MJ Jr, Scott MJ Sr. Ungual lichen planus. Lichen planus of
the nails. Arch Dermatol 1979; 115: 1197.
6. Vero F. Lichen planus of the nails. Arch Derm Syph 1932; 26:
677-83.
7. Zaias N. The nail in lichen planus. Arch Dermatol 1970; 101:
264-71.
8. Cram DL, Kierland RR, Winkelmann RK. Ulcerative lichen planus on
the feet. Arch Dermatol 1966; 93: 962-701.
9. Kofoed ML, Wantzin GL. Familial lichen planus. J American Acad
Dermatol 1985; 1: 50-4.
10. Rook A, Wilkinson D.S, Ebling FJG. Textbook of Dermatology.
Fifth edition, Oxford. Ed. Blackwell Scientific Publications, 1682-5.
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