Derm Dx: Rough, ridged fingernails and toenails


  • Trachyonychia_0314 Derm Dx

An 8-year-old male presents with his parents. They complain that for the past 4 months his nails have been “all messed up.“ He has no other medical problems.

The patient’s physical exam is completely normal with the exception of the appearance of his fingernails and toenails. All twenty nails have a roughened texture, as if they had been rubbed with coarse sandpaper.

Submit your diagnosis from the choices on the right to see the full explanation and answer.See how your colleagues responded.You must be logged in to make your diagnosis.Trachyonychia is also called "twenty-nail dystrophy" or "sandpapered nails." The condition consists of...

Submit your diagnosis to see full explanation.

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Trachyonychia is also called “twenty-nail dystrophy” or “sandpapered nails.” The condition consists of a spectrum of nail plate surface abnormalities that result in brittle and cosmetically unappealing nails.

Trachyonychia has the potential to involve all 20 nails. If it does, the condition is called “twenty-nail dystrophy.” However, since the nail changes do not always involve all 20 nails, the term trachyonychia (from the Greek word rough) is preferred.

Trachyonychia may occur in association with inflammatory conditions or autoimmune conditions, or it may be idiopathic. Most commonly, trachyonychia is found in association with alopecia areata and classically lichen planus. Trachyonychia is also infrequently seen in other inflammatory conditions that can cause disturbances in nail matrix, such as eczema and psoriasis.

Trachyonychia has also been reported in autoimmune processes such as selective IgA deficiency, vitiligo, sarcoidosis and graft-versus-host disease. Unilateral occurrence may occur in complex regional pain syndrome, a condition that results in severe pain and skin changes due to localized nervous system dysfunction.

 Idiopathic trachyonychia and the twenty-nail dystrophy variant are more common in children.

Clinically, the nails are thin, opaque and fragile. They will seem as if they have been sandpapered in a longitudinal direction resulting in longitudinal ridges with distal notches. The cuticles are often hyperkeratotic, and therefore appear thickened. Trachyonychia is mostly asymptomatic and patients complain only of brittleness of the fingernails and the cosmetic appearance.

Nail biopsy is the diagnostic test of choice to determine the underlying inflammatory disease responsible for trachyonychia. However, biopsy is generally not performed because of the benign nature of the disease. Trachyonychia improves spontaneously in the majority of patients. In one study, 50% of children with trachyonychia had the condition clear within 6 years.

Treatment is usually not necessary given spontaneous resolution.  If there is concomitant hair manifestation such as alopecia areata, systemic corticosteroids used to treat alopecia areata may improve trachyonychia. If there is concomitant psoriasis, systemic medications for psoriasis may be beneficial.

Other answer choices

Onychomadesis, also known as nail shedding, is an often traumatically induced shedding of the nail at its proximal end. The pathophysiology of onychomadesis entails the temporary arrest of the function of the nail matrix. As a result of this arrest, the nail plate detaches from the proximal nail fold. Onychomadesis therefore appears as a sulcus that replaces the proximal nail plate.

The arrest is most commonly a result of trauma (manicures, onychotillomania) but may also be caused by chronic paronychia, eczema of the proximal nail fold, neurologic disorders, peritoneal dialysis, cutaneous T-cell lymphoma, Kawasaki’s disease, pemphigus vulgaris, drug allergy, chemotherapy and keratosis punctate palmaris et plantaris.

Onychomycosis, also known as tinea unguium, is a term used to encompass all fungal infections of the nail and is most often caused by dermatophytes like Trichophyton rubrum, with non-dermatophytes accounting for approximately 10% of cases.

Onychomycosis is divided into four patterns based upon the point of fungal entry into the nail unit. The most common subtype is distal subungual, which is due to invasion of the infection via the hyponychium and distal nail bed. Distal subungual is usually caused by T. rubrum.

The second subtype, superficial white onychomycosis, is due to direct penetration into the dorsal surface of the nail plate and is often due to T. mentagrophytes.

The third subtype, proximal subungual is due to invasion under the proximal nail fold and is most commonly found in immunocompromised patients. Like distal subungual, proximal subungual is also most commonly caused by T. rubrum

The last subtype, candidal onychomycosis, produces destruction of the nail and massive nail bed hyperkeratosis. This subtype is found in patients with chronic mucocutaneous candidiasis.

Onycholysis is a spontaneous separation of the nail plate that begins at the free margin and progresses proximally. The nail itself has no inflammation during this process, and discoloration may occur under the nail due to bacteria/yeast accumulation.

Onycholysis is more commonly found in women due to traumatically induced separation or chemical causes. Traumatic causes include foreign body implantation and manicuring. Chronic exposure to chemicals like nail polish, nail hardeners, or artificial fingernails may also cause onycholysis. 

Other common causes include hand dermatitis, chronic exposure to irritants, untreated dermatitis, and secondary infection with candida. There are many systemic causes including common conditions such as hypo- or hyperthyroidism and pregnancy. Chemotherapy and systemic retinoids have also been associated with onycholysis.

Christopher Chu, BS, is a medical student at Baylor College of Medicine.

Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine also in Houston.


  1. Bolognia J, Jorizzo JL and Rapini RP. “Chapter 72 – Oral Disease.” Dermatology. St. Louis, Mo.: Mosby/Elsevier, 2008. Print.
  2. James WD, Berger TG, Elston DM et al. “Chapter 34 – Disorders of the Mucous Membranes.” Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006. Print.
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