A 25-year-old male, a diagnosed case of pulmonary langerhans cell histiocytosis (LCH) had undergone three cycles of vinblastine chemotherapy in the last 3 months. He was referred to dermatology regarding nail changes for the past 1 year. Examination of finger and toe nails revealed onycholysis [Figure 1a], subungual hyperkeratosis [Figure 1b], onychoschizia, onychorrhexis [Figure 1c], trachyonychia, and splinter hemorrhages [Figure 2a and 2b]. There were no lesions elsewhere over the body. Potassium hydroxide nail mount, Gram’s stain and culture were unremarkable. Blood examination was noncontributory. The diagnosis of nail changes secondary to LCH was made after ruling out onychomycosis, nutritional deficiency and chemotherapy induced nail changes.
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Figure 1: (a–c) Finger nails show onycholysis, splinter hemorrhages, and subungual hyperkeratosis (a and b). Thumb nails show onychoschizia, onychorrhexis, trachyonychia, and dystrophy (c)
Figure 2: (a and b) Toe nails show onycholysis, onychoschizia, trachyonychia, splinter hemorrhages (a), and subungual hyperkeratosis (b)
LCH is a group of hyperplastic cellular diseases of unknown causes. Fingernails or toe nails are rarely affected in LCH.[1] Extensive nail changes have been described in the pediatric population, but the literature for adults is lacking. Nail involvement represents an unfavorable sign of multisystem disease with the involvement of high-risk organs, but it is controversial.[2] LCH manifests in nails as subungual hyperkeratosis, purpuric striae, subungual pustules, onycholysis, longitudinal grooving, and paronychia. The index case had developed significant nail changes much before the commencement of vinblastine chemotherapy. Vinblastine chemotherapy may also induce nail changes such as melanonychia, mee’s lines, and onychomadesis, but these were absent in our case.[3]
The patient reported stabilization and mild improvement of nails after the commencement of chemotherapy along with systemic improvement. Delaval et al.[4] described resolution of nail changes in an adult LCH patient after 6 months of chemotherapy. We hypothesized that nail changes in LCH indicates a severe disease and an improvement in nails after chemotherapy may be a good indicator of response to treatment.
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References
1. Mataix J, Betlloch I, Lucas-Costa A, Pérez-Crespo M, Moscardó-Guilleme C. Nail changes in Langerhans cell histiocytosis: A possible marker of multisystem disease. Pediatr Dermatol 2008;25:247–51.
2. De Berker D, Lever LR, Windebank K. Nail features in langerhans cell histiocytosis. Br J Dermatol 1994;130:523–7.
3. Pavey RA, Kambil SM, Bhat RM. Dermatological adverse reactions to cancer chemotherapy. Indian J Dermatol Venereol Leprol 2015;81:434.
4. Delaval L, Bouaziz JD, Battistella M, Lorillon G, Tazi A. Nailing the diagnosis: Severe nail involvement in adult pulmonary Langerhans cell histiocytosis. Thorax 2021 ;76:102–3.
