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Apologies for the quality of the pictures but they were taken with my phone.

These nails belong to a 17 year old girl. the onychoschizia has been ongoing for 3-4 years, and is now becoming something that is 'bothering' this young lady. the transverse fissures appear across both hallux nails at regular intervals. At the point of the fissure the nail does not appear to be attached to the nail bed, but at either side of the fissure is fully attached. She has to wait until the nail has grown fully before the most distal fissure can be cleanly clipped away. The most number of fissures have been three, but there are usually two. The nails are very strong and brittle. There is no evidence of onychomycosis. They do not appear to be being caused by any trauma. Medication consists of Melatonin and Fluoxetine, but these are recent prescriptions (within the last year). There is a history of an eating disorder (not anorexic) but strictly watching food consumption, that was related to a serious case of bullying at senior school. These are now resolved (within 18 months - change of school helped!)

I have tried to research what could possibly be the cause, and have come up with possible vitamin/mineral deficiency (perhaps connected with her menstrual cycle) as they seem to appear at such regular intervals.

Any help would be greatly appreciated.

 

Hi Jacqui,

Beaus Lines with onychoschizia (love that word) can indicate, amongst a number of causes, a metabolic disorder, poor nutritional status or drug sensitivity. That said, many cases are idiopathic. Difficult to see from the pics, is there any evidence of koilonychia? Spooning often accompanies transverse onychoschizia.

You may find these links useful;

http://www.jfponline.com/Pages.asp?AID=6492

https://www.dermquest.com/image-library/image/?_id=5044bfd0c97267166cd65bdc

Cheers,
Bel

 

Thanks for the links. Sorry about the quality of the pictures, we had a young girl who wouldn't sit still, me trying to hold the toe in place and operate the camera function of a phone - need I say more?

There is no koilonychia. All nails including fingernails grow very straight. I initially thought the Melatonin could be the cause, but she has been on that for just over a year and the nail problem goes back further than that.

I have known her since she was born, and know that senior school was particularly difficult for her and she coped in her own special way - the only thing she could control was what she was putting in her mouth. For a long time her parents battled to get her to eat more than 500 calories a day. She is now improving so hopefully if it's due to poor nutrition then things will start to improve. I'll suggest she sees her GP for blood tests.

Many thanks. J x

 

Most general conditions affecting the whole body, metabolic or nutritional etc would affect all the nails, not selectively the hallux.
This is most likely caused by short or Ill fitting footwear, causing a trauma to the distal end of the nail, irritating the germinative part of the nail bed, which may not be noticed as a single traumatic event by the patient.
I advise checking shoes for fit and fastening.

 

I agree that footwear should be examined as trauma can be associated with beau`s lines. However, systemic illness is often only observed the hallux bilaterally, see below taken from here;

Given the patients history, I would suggest poor nutrition is a factor in the presenting complaint. There also appears to be mild paronychia, does she `pick` at the nail folds? Dermatillomania is sometimes associated with anxiety and stress and can lead to tissue damage.

Cheers,
Bel

 

Thank you both for your replies.

Footwear and a gait analysis were my first choice, thinking that the trauma was being caused mechanically. It was only when I started to delve into the medical side of things that the events of the last few years came to fore.

I think Blinda has really hit the nail on the head, it was the way I was going, but needed a sounding board, and to make sure I wasn't missing anything less obvious.

Thanks .... now to make the phone call!

Cheers, Jx

 

It`s an interesting case, Jacqui. Thanks for sharing :drinks

Blood tests may reveal deficiencies brought about by poor nutrition. However, whilst she doesn`t present with the usual `washboard` appearance, if she is struggling with stress disorders, and picking at the nail folds/nails, she may well be unwittingly inflicting the ridges herself. I found this on Onychotillomania;

http://www.merckmanuals.com/professional/dermatologic_disorders/nail_disorders/nail_deformities.html

 

I agree with Blinda and her suggestions and would follow them up seriously.

However, the Beau's lines can be traced to a possible time frame (2 months for 1/3rd the nailplate).

Perhaps this gal is participating in a sport/activity in which she is wearing tightly fitted shoes (especially of the hallux) that is calling upon random excesses of activity (TS)?

This could reflect historic moments when she has multiple practices/games/tourneys, where her hallux toenails are getting smashed and compressed.

I see this often in elite football (soccer) players along with Onychomedsis.

Dennis

 

Thanks for the suggestions. She is not a sporty individual, tends to keep to herself (as a result of the bullying issues). Family have been brilliant on working on her self esteem issues and she now runs her own business! But having spoken with the family re the nutrition issues it seems to fit all the boxes. she's recently been diagnosed with mild aspergers which is the cause of the food intake problems and apparently she suffers really badly with heavy periods that leave her totally washed out but cannot take anything (pill etc) to counteract them because of embolism history in the family (mum and grandmother). GP appointments are being sought in order to have a full blood history taken including vitamin/mineral deficiencies and to look at other ways of helping with the periods. Will keep you posted.