REDISCOVERING
THE PHYSICAL EXAM
Trachyonychia
A
healthy 7-year-old girl presented with progressive
discoloration and roughness of her fingernails and
toenails that began 8 months earlier. The dystrophic
changes in the nails gradually increased over time.
Physical examination revealed sandpaper-like fingernails
and toenails with roughness and longitudinal ridging
(Figure 1 and Figure 2 [available at www.jpeds.com]).
Most of the nails were opaque and lusterless. The adjacent
cuticles were thickened.
Typically, trachyonychia, also known as 20-nail dystrophy,
presents with roughness of the nail plate associated with lon-
gitudinal ridging that may give the nail an opaque,
sandpaper-like appearance (opaque trachyonychia) as is
illustrated in the present case.1 Less commonly, trachyony-
chia presents with diffuse, closely aggregated, small superfi-
cial pits that reflect light that may give the nail a shiny
appearance (shiny trachyonychia).1,2 The 2 varieties may
coexist.
Trachyonychia may involve the nail of 1, several, or all
digits. The degree of severity may, however, vary from nail
to nail. Typically, the involvement is bilateral and symmetri-
cal. Multiple nails are usually affected at the time of presen-
tation.3 The adjacent cuticles are usually ragged,
hyperkeratotic, and thickened.2 Affected nails are often thin
and brittle.4 Koilonychia is commonly seen.
Figure 1. Close-up of the left index and middle fingernails
showing a rough surface, “sandpapered” appearance, and
longitudinal ridging. Note the thickening of the cuticle.
J Pediatr 2019;-:-.
0022-3476/$ - see front matter. ª 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jpeds.2019.08.034
Although trachyonychia can occur at any age, the peak age of
onset is between 3 and 12 years.1,2 In the pediatric age group,
the condition is more commonly seen in males, whereas
adult-onset trachyonychia has a female predominance.2,5
The majority of cases occur sporadically and are idio-
pathic.2,6 However, trachyonychia has been reported in asso-
ciation with a number of dermatologic diseases (eg, alopecia
areata, atopic dermatitis) and nondermatological diseases
(eg, immunoglobulin A deficiency, autoimmune hemolytic
anemia, immune thrombocytopenia).1-6
Trachyonychia should be differentiated from onychomycosis,
which typically presents with yellow-brown or white discolor-
ation of the nail. Other clinical manifestations of onychomycosis
include subungual hyperkeratosis, onycholysis, onychauxis, and
dermatophytoma (Figure 3; available at www.jpeds.com). The
latter is specific for onychomycosis. Onychomycosis is much
more common in adults than in children whereas the onset in
trachyonychia is usually in childhood.
The majority of children with isolated trachyonychia have
significant improvement or spontaneous resolution of their
nails with time, regardless of treatment.7 n
Alexander K.C. Leung, MBBS, FRCPC, FRCP(UK & Irel),
FRCPCH, FAAP
Department of Pediatrics
University of Calgary and Alberta Children’s Hospital
Calgary, Alberta, Canada
Kin Fon Leong, MBBS, MRCPCH
Pediatric Institute
Kuala Lumpur General Hospital
Kuala Lumpur, Malaysia
Benjamin Barankin, MD, FRCPC
Toronto Dermatology Center
Toronto, Ontario, Canada
References
1. Blanco FP, Scher RK. Trachyonychia: case report and review of the liter-
ature. J Drugs Dermatol 2006;5:469-72.
2. Haber JS, Chairatchaneeboon M, Rubin AI. Trachyonychia: review and
update on clinical aspects, histology, and therapy. Skin Appendage Disord
2017;2:109-15.
3. Chu DH, Rubin AI. Diagnosis and management of nail disorders in chil-
dren. Pediatr Clin North Am 2014;61:293-308.
4. Gordon KA, Vega JM, Tosti A. Trachyonychia: a comprehensive review.
Indian J Dermatol Venereol Leprol 2011;77:640-5.
5. Chernoff KA, Scher RK. Nail disorders: kids are not just little people. Clin
Dermatol 2016;34:736-41.
6. Jacobsen AA, Tosti A. Trachyonychia and twenty-nail dystrophy: a
comprehensive review and discussion of diagnostic accuracy. Skin
Appendage Disord 2016;2:7-13.
7. Kumar MG, Ciliberto H, Bayliss SJ. Long-term follow-up of pediatric tra-
chyonychia. Pediatr Dermatol 2015;32:198-200.
1
THE JOURNAL OF PEDIATRICS  www.jpeds.com Volume -  - 2019

Figure 2. The toenails, especially the big toes, had a rough

surface, longitudinal ridges, and a “sandpapered” appear-
ance.

Figure 3. Onychomycosis. Note the yellow discoloration of

right thumbnail with subungual hyperkeratosis, onycholysis,
and onychauxis.

1.e1 Leung, Leong, and Barankin