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A 16-year-old boy presents to the clinic with concerns about changes to his nails that were first noted several weeks ago. The patient is in good health and takes no oral medications or supplements. He has no history of diabetes or thyroid disease and has received 2 COVID-19 vaccinations. Approximately 3 months ago he was diagnosed with hand, foot, and mouth disease that manifested as scattered vesicles and slight fever. Examination of his finger and toenails reveals detachment of the nail plate.
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Onychomadesis is a benign process that involves separation of the nail plate from the nail bed.1 The shedding of the nail plate is a direct result of arrest of the nail matrix. Interruption of nail growth leads to detachment of the nail plate from the nail bed.2 The new nail grows without being attached to the older one resulting in further splitting and detachment of the older nail.
Nail matrix arrest can be engendered by a number of conditions such as local infection, systemic illnesses, autoimmune diseases, medications, and trauma.2 In the pediatric population, onychomadesis is common after hand, foot, and mouth disease (HFMD) and occurs several weeks after infection.2,3 The presence of coxsackievirus A6 in samples taken from nail plates of patients with onychomadesis has led to the hypothesis that the virus may directly damage the nail matrix, resulting in the shedding on the nail plate.4
Onychomadesis is asymptomatic and self-limiting. Parents and patients should be reassured of the benign clinical course of this condition to mitigate anxiety and unnecessary referral to a specialist.5 Treatment entails clipping the detached nail plate to prevent it from getting caught on clothing and other environmental objects.
Sara Mahmood, DPM, is a podiatrist who completed a joint dermatology/podiatry fellowship and is on staff at DermDox Dermatology Centers in Pennsylvania. Stephen Schleicher, MD, is director of the DermDox Dermatology Centers, associate professor of medicine at Geisinger Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.
References
1. Hardin J, Haber RM. Onychomadesis: literature review. Br J Dermatol. 2015;172(3):592-596. doi:10.1111/bjd.13339
2. Apalla Z, Sotiriou E, Pikou O, et al. Onychomadesis after hand-foot-and-mouth disease outbreak in northern Greece: case series and brief review of the literature. Int J Dermatol. 2015;54(9):1039-1044. doi:10.1111/ijd.12592
3. Smith RJ, Rubin AI. Pediatric nail disorders: a review. Curr Opin Pediatr. 2020;32(4):506-515. doi:10.1097/MOP.0000000000000921
4. Chiu HH, Liu MT, Chung WH, et al. The mechanism of onychomadesis (nail shedding) and Beau’s lines following hand-foot-mouth disease. Viruses. 2019;11(6):522. doi:10.3390/v11060522
5. Akpolat ND, Karaca N. Nail changes secondary to hand-foot-mouth disease. Turk J Pediatr. 2016;58(3):287-290. doi:10.24953/turkjped.2016.03.009
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