Nail changes in alopecia areata: Incidence and pattern

Introduction

Alopecia areata (AA) is a immune mediated, disease presenting with non-cicatricial alopecia occurring in a circumscribed or generalized pattern. Apart from hair, abnormalities of nails and eyes have been reported specially in more severe varieties like alopecia totalis and universalis. Nail involvement in AA may either precede or follow development of alopecia patches. Nail changes may persist for a long period of time after complete hair regrowth. The present study was conducted to observe the frequency, extent and severity of nail involvement in Indian patients.

Materials and Methods

The study incorporated 100 consecutive patients of AA attending Dermatology outpatients services at GTB Hospital over a 6 month period. Each patient was subjected to a thorough clinical examination of hair and nails. Other relevant investigations like KOH examination of hair roots and nails were done where indicated. Other causes of nail changes like psoriasis and chronic eczemas were excluded by history and clinical examination.

Observations

The duration of disease varied from a few week to years [Figure - 2].

Different varieties of alopecia areata observed were:

1. Focal 16

2. Multifocal 64

3. Ophiasis 18

4. Tofolis 2

Nail changes were observed in 44/100 (44%) patients. The different nail changes observed were as follows:

1. Pitting 28

2. Longitudinal striations 10

3. Lomellar solittina 18

4. Trachyonychia 9

5. Distal notching 2

6. Ragged cuticles 2

7. Beau′s lines 2

Association between nail changes and clinical variety:

1. Multifocal 30/44 (68%)

2. Ophiasis 12/44 (27%)

3. Totalis 2/44 (4.5%)

None of the patients in focal variety had nail changes.

Discussion

The incidence of nail changes in AA is recorded as ranging from 7% to 66%.[1],[2],[3] The nail changes observed include diffuse fine pitting, onychorrhexis, Beau′s lines, longitudinal ridging, onychodystrophy and trachyonychia.[4] Gross nail dystrophy is said to be proportional to the degree of hair loss.[1] Thus, marked changes occur more commonly in alopecia totalis and universalis. Nail changes may either precede, accompany or follow the hair loss. They may persist even after hair regrowth. In our study, 44/100 (44%) patients had nail changes. The commonest change observed was superficial pits seen in 28/100 (28%) patients. The clinical variety of AA associated predominantly was multifocal variety (30/44-68%) in contrast to focal variety where none of the patients demonstrated nail changes. Thus the presence of nail changes in AA can be considered an indicator of severity of the disease and probably reflects a more refractory disease as compared to patients with absence of nail changes. In a large study from Northern India, Sharma et al[5] found nail changes in 20% of patients of AA and more frequently in severe forms of AA(47%). In another study in pediatric population,[6] same authors found nail changes in 30% patients and observed that nail involvement was more frequent in severe alopecia(53%) than in circumscribed alopecia(25.2%). We conclude that involvement of nails in alopecia areata is an important prognostic indicator of disease severity.