Clinical Dermatology Review

: 2022  |  Volume : 6  |  Issue : 2  |  Page : 152-

Twenty nail dystrophy: A feature of direct nail apparatus involvement in leprosy

Ashish Kumar Nayak1, Biswanath Behera1, Siddhartha Dash1, Madhusmita Sethy2, Aparna Palit1,  
1 Department of Dermatology and Venereology, AIIMS, Bhubaneswar, Odisha, India
2 Department of Pathology and Laboratory Medicine, AIIMS, Bhubaneswar, Odisha, India

Correspondence Address:
Siddhartha Dash
Department of Dermatology and Venereology, AIIMS, Bhubaneswar - 751 019, Odisha


Lepromatous leprosy (LL) is a systemic illness which involves various organs either directly due to Mycobacterium leprae or as a part of lepra reaction. Nail changes occur in leprosy with variable frequency but may not have a direct causal relationship with leprosy. Hereby, we are describing a case of untreated LL presenting with twenty nail dystrophy and a direct causal relationship of the same due to M. leprae.

How to cite this article:
Nayak AK, Behera B, Dash S, Sethy M, Palit A. Twenty nail dystrophy: A feature of direct nail apparatus involvement in leprosy.Clin Dermatol Rev 2022;6:152-152

How to cite this URL:
Nayak AK, Behera B, Dash S, Sethy M, Palit A. Twenty nail dystrophy: A feature of direct nail apparatus involvement in leprosy. Clin Dermatol Rev [serial online] 2022 [cited 2022 Nov 29 ];6:152-152
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It has been aptly stated that systemic illnesses are reflected in nails. Lepromatous leprosy (LL) may have multi-organ involvement due to the direct effect of Mycobacterium leprae, or as part of type 2 lepra reaction. Hence, it is no wonder that the disease may leave its footprints on nails as well. Nail changes have been reported in up to 64%–87% leprosy patients with variable frequency among paucibacillary (PB) and multibacillary (MB) disease.[1],[2],[3] Most of the nail changes described in leprosy [Table 1] may not have a direct causal relationship to the disease.[1],[2],[3],[4],[5] Twenty nail dystrophy is usually seen in psoriasis, lichen planus, onychomycosis, epidermolysis bullosa, dyskeratosis congenita, congenital mucocutaneous candidiasis, systemic amyloidosis, and may be idiopathic. Isolated nail dystrophy has been described in patients with leprosy.[2],[3] Hereby, a case of untreated LL presented with twenty nail dystrophy has been reported.{Table 1}

 Case Report

A 54-year-old, male farmer presented with multiple, nodular skin lesions progressively increasing over the past 20 years. For the past 4 years, he had developed spontaneous blistering of toes, intermittent pedal edema, and nasal stuffiness. He did not have any addiction, diabetes, and cardiovascular comorbidities.

Clinical examination revealed diffuse infiltration of face, pinna, and trunk with generalized shiny skin colored nodules and bilateral madarosis. There were bilateral, symmetrical peripheral nerve thickening with gloves and stockings hypoesthesia. Anterior nasal mucosa was pale with edematous inferior turbinates and crusts. Generalized significant lymphadenopathy was present.

A striking clinical finding was complete structural damage of all twenty nails. There was brownish - black discoloration and crumbling of the nail plates with thick subungual debris [Figure 1]. Other noticeable findings in some of the nails were onycholysis, tenting, splitting, transverse grooves, and overcurvature.{Figure 1}

A clinical diagnosis of untreated LL with grade 1 deformity of hands and feet (World Health Organization [WHO], 1988) along with twenty nail dystrophy was made and the patient was investigated.

X-ray of the hands and feet did not reveal obvious bony abnormalities. Skin biopsy from a nodule was consistent with histopathological features of LL. Fine-needle aspiration cytology from an enlarged lymph node was consistent with lepromatous lymphadenitis with the presence of solid-stained bacilli.

The patient was worked up to establish the cause of twenty nail dystrophy. Potassium hydroxide mount of multiple nail clippings did not demonstrate fungal elements, and the culture was sterile. Biopsy from the nail bed [Figure 2]a and nail matrix [Figure 2]b showed thinned epidermis, and dense infiltrate composed of lymphocytes, histiocytes, and Virchow cells. Fite stain was positive, bacillary index being 6 + [Figure 2]c, and 5 + [Figure 2]d, respectively. The WHO Multidrug therapy, the MB regimen was started.{Figure 2}


Various nail changes have been described in all spectra of leprosy. Age-related changes, peripheral neuropathy, vascular involvement related to type 2 lepra reaction, effects of anti-leprosy drugs, repeated trauma, and secondary infections have been cited as probable etiological factors for nail changes in leprosy.[2],[3],[4] Bhushan et al. have reported a patient with single borderline tuberculoid (BT) lesion on hand with nail involvement along the distribution of the enlarged ulnar nerve supporting direct nail involvement due to BT leprosy.[5] However, the direct role of M. leprae in the causation of these nail changes remains inconclusive because of the dearth of histopathological evidence and the presence of the bacillus in the nail apparatus.

Dystrophy of few finger and toenails has been reported in both PB and MB leprosy. Overall finger and toe-nail dystrophy were observed among 8.3%–20% and 0%–13.8% of tuberculoid and lepromatous patients, respectively.[3] The maximum number of nails involved were two (fingers) and seven (toes) in tuberculoid and eight (fingers) and five (toes) among lepromatous patients.[3]

Although all nails were involved, there was no apparent radiological abnormality of the distal phalanges in this patient. Histopathological evidence of LL and demonstration of M. leprae in nail bed and matrix were supportive to causal relationship in this case. The probable cause of uniform involvement of all the twenty nails was that the patient's disease remained untreated for a prolonged period. M. leprae, an organism preferring cooler, peripheral body sites had resulted in unprecedented damage to the nail apparatus resulting in this unusual clinical presentation.

Other common causes of twenty nail dystrophy are alopecia areata, lichen planus, and psoriasis. Associated cutaneous lesions of the respective disease over the nail folds or other areas of skin can help in clinching the diagnosis. The important associated nail findings of these diseases have been discussed [Table 2].[6]{Table 2}


Some of the nail changes in leprosy patients may be related to the disease per se, as was the twenty nail dystrophy in this case. Rudimentary nails and complete loss of nails or anonychia[1],[2],[4] are also specific findings related to leprous rarefying osteitis and concentric atrophy, involving terminal phalanges. Other reported findings may be multifactorial related to age, socioeconomic status, occupation, nutrition, presence of comorbid illnesses, congenital deformities, and unnoticed trauma to anesthetic hands and feet.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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