212 CLINICAL REPORT
ActaDV ActaDV Advances in dermatology and venereology Acta Dermato-Venereologica
Nail Involvement in Alopecia Areata: A Questionnaire-based Survey on Clinical Signs, Impact on Quality of Life and Review of the Literature
Yvonne B. M. ROEST 1, Henriët VAN MIDDENDORP 2, Andrea W. M. EVERS 2, Peter C. M. VAN DE KERKHOF 1 and Marcel C.
PASCH 1 1
Department of Dermatology, Radboud University Nijmegen Medical Center, Nijmegen, and 2 Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, The Netherlands
Alopecia areata( AA) is an immune-mediated disease causing temporary or permanent hair loss. Up to 46 % of patients with AA also have nail involvement. The aim of this study was to determine the presence, types, and clinical implications of nail changes in patients with AA. This questionnaire-based survey evaluated 256 patients with AA. General demographic variables, specific nail changes, nail-related quality of life( QoL), and treatment history and need were evaluated. Prevalence of nail involvement in AA was 64.1 %. The specific nail signs reported most frequently were pitting( 29.7 %, p = 0.008) and trachyonychia( 18.0 %). Red spots on the lunula were less frequent( 5.1 %), but very specific for severe AA. Nail-related QoL was only minimally affected by nail changes. In conclusion, nail involvement is common in patients with AA and presents mostly with pitting and trachyonychia. The presence of these nail changes reflects the severity of the disease, with red spots on the lunula as a predictor for severe alopecia.
Key words: alopecia areata; quality of life; prevalence; nail disease; survey.
Accepted Oct 2, 2017; Epub ahead of print Oct 2, 2017 Acta Derm Venereol 2018; 98: 212 – 217.
Corr: Yvonne B. M. Roest, Department of Dermatology,( 370), Radboud University Nijmegen Medical Center, PO Box 9101, NL-6500 HB Nijmegen, The Netherlands. E-mail: Yvonne. Roest @ radboudumc. nl
Alopecia areata( AA) is an immune-mediated disease that is characterized by non-scarring hair loss. The disease may be limited to one or more discrete, wellcircumscribed round or oval patches of hair loss on the scalp or body( alopecia areata focalis; AAF), or it may affect the entire scalp( alopecia areata totalis; AAT), or even the entire body( alopecia areata universalis; AAU). The natural course of the disease is unpredictable, but often benign. Spontaneous regrowth of hair occurs in 80 % of patients within the first year, but relapses at any given time are not uncommon. Poor prognostic factors include bald patches persisting for more than one year, onset of hair loss before puberty, a positive family history of AA, ophiasis pattern, associated nail changes, atopy, and Down syndrome( 1). Severity of AA at onset is perhaps the most important negative prognostic factor( 2). A lifetime incidence between 0.57 % and 3.8 % has been reported in hospital-based studies worldwide( 3). AA may appear at any age, but as many as 60 % of patients with AA will present with their first patch before 20 years of age( 4), and prevalence peaks between the 2 nd and 4 th decades of life( 1).
AA is a lymphocyte cell-mediated inflammatory form of hair loss in which a complex interplay between genetic factors and underlying autoimmune aetiopathogenesis is suggested, although the exact aetiological pathway is unknown( 5). Some studies have shown association with other auto-immune diseases, including asthma, atopic dermatitis, and vitiligo( 6).
Many patients with AA also have nail involvement, with a reported incidence ranging from 9 % to 46 %( 7, 8). Incidence is much lower in patients with focal AA than in patients with severe forms of AA( 9, 10), and may be higher in children than in adults( 8, 11). Nail changes may either precede the hair loss or occur months or years later, and may persist even after hair regrowth. The pathogenic mechanism of nail changes in AA is unknown, but it has been proposed that because the nails are similar in structure and growth to hair follicles, they are affected by the same inflammatory reaction that targets hair follicles in AA. Histopathological observations using light and electron microscopic techniques show that most of the nail changes in AA are found within the proximal matrix, and are less pronounced in the distal matrix, and negligible in the nail bed( 12). The fact that the nail matrix is far more often involved than the nail bed results in a clinical presentation of matrix-derived nail changes that may include pitting, trachyonychia, onychorrhexis, Beau’ s lines, onychomadesis, and nail thinning with or without koilonychia( 8). Anonychia and scarring are not typically seen. Red spots on the lunula are rarely present, but are highly suggestive for the diagnosis AA( 13). Nail bed signs are uncommon and only one case of severe onycholysis has been reported to date( 14).
Studies in the field of nail changes in patients with AA are sparse. The aim of this study was to evaluate nail involvement in patients with AA, the impact on quality of life( QoL), and to evaluate a potential unmet need for treatment.
MATERIALS AND METHODS Patients
This study was conducted in collaboration with the Dutch Alopecia Patient Association between April 2013 and October doi: 10.2340 / 00015555-2810 Acta Derm Venereol 2018; 98: 212 – 217
This is an open access article under the CC BY-NC license. www. medicaljournals. se / acta Journal Compilation © 2018 Acta Dermato-Venereologica.