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Nail Lichen Planus

      A 56-year-old woman presented with a 1-year history of altered nail growth and fragility, causing pain and cosmetic concern. Examination revealed onychodystrophy of multiple fingernails and toenails, with onycholysis, distal nail plate splitting, pterygium, longitudinal ridging, and subungual hyperkeratosis (Figure). She had a concomitant pruritic eruption on her chest and extremities and gingival ulceration. The scalp and vulva were uninvolved.
      Figure thumbnail gr1
      FigureNail lichen planus showing subungual hyperkeratosis and onychorrhexis (A) and onycholysis, dorsal nail plate splitting, and pterygium formation (B).
      The periodic acid–Schiff stain reaction of nail clippings was negative for fungus. Matrical biopsy showed focal lichenoid interface inflammation. Clinical and histopathologic findings led to a diagnosis of lichen planus. The patient’s nails improved several months after intralesional triamcinolone injections to affected matrices, topical triamcinolone cream to affected proximal nail folds, and oral mycophenolate mofetil and hydroxychloroquine (Supplemental Figure 1, available online at http://www.mayoclinicproceedings.org).
      Nail lichen planus is manifested with nail plate thinning, longitudinal ridging, distal nail plate splitting, onycholysis, onychorrhexis, subungual hyperkeratosis, lunular erythematous patches, and pterygium.
      • Tosti A.
      • Peluso A.M.
      • Fanti P.A.
      • Piraccini B.M.
      Nail lichen planus: clinical and pathologic study of twenty-four patients.
      • Zaias N.
      The nail in lichen planus.
      • Goettmann S.
      • Zaraa I.
      • Moulonguet I.
      Nail lichen planus: epidemiological, clinical, pathological, therapeutic and prognosis study of 67 cases.
      Nail lichen planus can occur independently or in association with mucocutaneous involvement.
      • Tosti A.
      • Peluso A.M.
      • Fanti P.A.
      • Piraccini B.M.
      Nail lichen planus: clinical and pathologic study of twenty-four patients.
      Differential diagnosis may include onychodystrophy from onychomycosis, psoriasis, alopecia areata, or trauma.
      • Lehman J.S.
      • Tollefson M.M.
      • Gibson L.E.
      Lichen planus.
      Clinical examination is often sufficient for diagnosis, but histopathologic features of bandlike lymphocytic infiltrate of nail matrix or bed epithelium (Supplemental Figure 2, available online at http://www.mayoclinicproceedings.org) are confirmatory.
      • Goettmann S.
      • Zaraa I.
      • Moulonguet I.
      Nail lichen planus: epidemiological, clinical, pathological, therapeutic and prognosis study of 67 cases.
      Treatment should be commenced promptly to avoid permanent nail dystrophy. First-line treatment of nail lichen planus is corticosteroids (topical, intralesional, or rarely, systemic), but persistence or relapse of disease may justify corticosteroid-sparing immunosuppressants.
      • Goettmann S.
      • Zaraa I.
      • Moulonguet I.
      Nail lichen planus: epidemiological, clinical, pathological, therapeutic and prognosis study of 67 cases.
      Nail lichen planus should be considered in the differential diagnosis of progressive nail changes, and patients with onychodystrophy should be examined carefully for other mucocutaneous manifestations of lichen planus.

      Supplemental Online Material

      References

        • Tosti A.
        • Peluso A.M.
        • Fanti P.A.
        • Piraccini B.M.
        Nail lichen planus: clinical and pathologic study of twenty-four patients.
        J Am Acad Dermatol. 1993; 28: 724-730
        • Zaias N.
        The nail in lichen planus.
        Arch Dermatol. 1970; 101: 264-271
        • Goettmann S.
        • Zaraa I.
        • Moulonguet I.
        Nail lichen planus: epidemiological, clinical, pathological, therapeutic and prognosis study of 67 cases.
        J Eur Acad Dermatol Venereol. 2012; 26: 1304-1309
        • Lehman J.S.
        • Tollefson M.M.
        • Gibson L.E.
        Lichen planus.
        Int J Dermatol. 2009; 48: 682-694