Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Case Letter
ARTICLE IN PRESS
doi:
10.25259/IJDVL_508_2022

Doxycycline-induced photo-onycholysis in a child: Case report and brief review

Department of Dermatology, AIIMS Bhopal, India
Department of Dermatology, All India Institute of Medical Sciences, Bhubaneswar, Cuttack, India
Corresponding author: Dr. Arpita Nibedita Rout, Department of Dermatology, All India Institute of Medical Sciences Bhubaneswar, Gopalpur Po Patapur Via Banki, Cuttack, Indiaarpitanrout1988@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Roy K, Asati DP, Rout AN, Doxycycline-induced photo-onycholysis in a child: Case report and brief review. Indian J Dermatol Venereol Leprol doi: 10.25259/IJDVL_508_2022

Dear Editor,

Doxycycline, a tetracycline antibiotic, is used for its macrofilaricidal action in filariasis. It is an infrequent cause of drug-induced phototoxic reaction. We report doxycycline-induced photo-onycholysis in a child with lymphatic filariasis along with onychoscopic findings and also a brief review of similar cases.

A 11-year-old girl presented with symmetric, painless, moon-shaped detachment of all distal fingernail plates, sparing the covered toenails for 2 weeks. She was a diagnosed filariasis with chronic lymphedema and was on oral diethylcarbamazine therapy for a year and doxycycline 100 mg daily for the past 4 weeks. She had a history of prolonged exposure to sunlight during the winter months. There was no history of any other drug intake. On examination, distal central moon-shaped onycholysis was noted involving all fingernails with a sharp yellow-brown proximal border [Figure 1a]. Overlying red–pink exogenous pigmentation was noted over the nail plate on the left hand, not clearing on scrubbing with 70% alcohol. Dermoscopic examination revealed yellow–brown background with white honeycombed pattern overlying the nail plate with a well-defined proximal margin [Figure 2]. No splinter haemorrhage, red dots or well-defined red-brown areas were noted. A negative potassium hydroxide (10%) mount of the nail clipping ruled out onychomycosis. Other routine investigations and thyroid profile were normal. She was advised to stop doxycycline, limit daily sun exposure and trim detached distal nail plate. Partial resolution without recurrence was seen at 3 months [Figure 1b].

Figure 1a:: Moon shaped distal onycholysis with sharp proximal margin and subungual debris
Figure 1b:: Partial improvement 3 months post cessation of therapy
Figure 2:: White honeycombing (black circle) with background yellow brown areas (blue arrow) and sharp proximal yellow border (red arrow)

Doxycycline-induced photo-onycholysis is an uncommon, benign event following prolonged intense sun exposure. Phototoxicity following doxycycline can occur immediately or several weeks after cessation of the drug. Exposure to UVB followed by UVA1 and visible light spectrum leads to generation of free radicals mediating DNA damage and cytotoxicity. 1

The selective transmission of ultraviolet rays through the convex nail plate results in painful, half-moon-shaped detachment due to concave shape of the cuticle, appearing white due to the separation of the nail plate from the vascular nail bed. 1 Blue–black discolouration due to subungual dirt accumulation and brown discolouration following subungual haemorrhage have been noted. Its occurrence with photo-induced skin rash and nail discolouration comprises the segals triad. 1

Baran et al. described three reaction patterns. Type 1, (most common pattern) in doxycycline-induced cases with characteristic half-moon shape with well demarcated pigmented proximal border in multiple fingers, Type 2, single digit with a prominent proximal circular notch, and Type 3, subungual haemorrhages in multiple fingers. 1

We reviewed the literature for a total of 15 such cases, whose demographic and therapeutic details are mentioned in Table 1. 14 Majority of the patients were on treatment for acne vulgaris, malaria prophylaxis and lyme disease. 2,3 Phototoxic reactions were common, seen in 12 cases (80%) with higher doses of doxycycline (≥200 mg), which was similar to the findings of Baran et al. 1 However, Pazzaglia et al. have reported a pediatric case developing photo-onycholysis following intake of doxycycline at dose as low as 20 mg, emphasizing the need for photoprotection at lower doses.

Table 1:: Summary of doxycycline induced photo-onycholysis cases (n = 16)
Author, year Study type (n = patients) Age (years) Dose Time to onset Type of onycholysis Concomitant medication Recovery
Our case, 2022 Case report (1) 11 l00 mg BD 3 weeks I Diethylcarbamazine (DEC) × 2 months Partial recovery at 1 month
Baran et al. 1 Case report (1) 10 200 mg Days NM NA NM
Lareb 2 Case series (12) 8–71 100–500 mg 1–12 weeks NM Citalopram

Full recovery (3)

No recovery (2)

Partial recovery (2)

Pazzaglia et al. 3 Case report (1) 13 20 mg OD 1 week I None Fully recovery in 3 months
Elmas et al. 4 Case report (1) 16 200 mg BD NM I None LTFU

BD: Twice a day, NM: Not mentioned, OD: Once a day, NA: Not applicable, DEC: Diethylcarbamazine, LTFU: Lost to follow up

As three patients (20%) who developed photo-onycholysis were under 8 years of age, we suggest that people in this age group to take adequate photoprotective measures while using the drug. The geographical location, season, patient behaviour, time of the day (solar zenith angle ≤ 45) and lighter skin types photo react more often than type IV (our case) or III. 1,4 Higher UV index (UVI) mandates strict photoprotection behaviour of the resident population with regulation of time of exposure to minimise adverse events. 5 Summer flare (54.5%) and beach visits were often noted.

Elmas et al. observed bluish black discolouration, brown dots and proximal brown discolouration with sharp linear edges on dermoscopy. 4 We report a novel dermoscopic pattern of ‘white honeycombing’ overlying nail plate with a well-defined proximal yellow–brown margin. A unique spiderweb pattern similar to our findings was reported by Chamli et al., however our case shows a coarser pattern than the former. 6

It is a benign, spontaneously resolving disease with few cases of permanent nail dystrophy. 2 Recurrence can occur if photoprotective measures are not followed with drug use.

Avoidance of sunlight is encouraged. Nail varnish is an added protective measure in females. Awareness of such presentations avoids unnecessary worry and investigations in cases with multiple nail haemorrhages simulating septic thrombi from endocarditis. The diagnostic importance of honeycomb pattern on dermoscopy should be explored in future.

Declaration of patient consent

Patient’s consent is not required as her identity is not disclosed or compromised.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.

References

  1. , . Drug-induced photo-onycholysis. Three subtypes identified in a study of 15 cases. J Am Acad Dermatol. 1987;17:1012-16.
    [CrossRef] [PubMed] [Google Scholar]
  2. . Doxycycline and photo-onycholysis—An update. https://databankws.lareb.nl/Downloads/KWB_2013_2_doxycycline_photo_onycholysis_WEB.pdf
  3. , , . Photo-onycholysis caused by an unusual beach game activity: A pediatric case of a side effect caused by doxycycline. Pediatr Dermatol. 2014;31:26-7.
    [CrossRef] [PubMed] [Google Scholar]
  4. , . A Case of Doxycyclin-induced photo-onycholysis with dermoscopic features. Balkan Med J. 2020;37:113.
    [CrossRef] [PubMed] [Google Scholar]
  5. . The shadow rule, the UV index, and the 5S steps in the tropics. Health Phys. 2020;119:358-62.
    [CrossRef] [PubMed] [Google Scholar]
  6. , , , , , , et al. Spiderweb-like pattern: A novel dermoscopic feature in photo-onycholysis induced by doxycycline? Therapie. 2021;76:49-50.
    [CrossRef] [PubMed] [Google Scholar]

Fulltext Views
2,107

PDF downloads
852
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections