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Elkonyxis is a condition that features irregular defects in the dorsal nail plate.1 It is clinically characterized by a punched-out lesion at the lunula that progressively moves distally with the growth of the nail.2 Elkonyxis has been described secondary to syphilis, psoriasis, Reiter’s syn-drome, and after trauma.2 It has also been reported in association with retinoid therapy2,3 and with peritonitis in a peritoneal dialysis patient.4 However, this rare nail dystrophy has been rarely reported. The terms “elkonyxis” and “elconyxis” are used synonymously in the literature, and it is difficult to establish their etymology.1,2 Herein, we report two cases of elkonyxis in association with washboard nail and 20-nail dystrophy.

A 68-year-old woman presented with a hemorrhagic crust on the left third fingernail, which had been injured by a door two months previously (Fig. 1a). On close inspection, a punched-out lesion was apparent at the lunula on the left third finger, as were multiple transverse grooves with a central depression on both thumb nails and the left second and third fingernails; these were clinically consistent with washboard nail (Fig. 1b). The cuticles of the nails involved were not observed. The patient had habitually pushed back the fingernail cuticles, and the washboard deformities had been present for eight years. Extraction of the nail plate and a 2-mm punch biopsy were performed. Histopathology of the crusted lesion showed chronic inflammation and necrotic tissue (Fig. 1c, d). The elkonyxis on the left third finger improved with symptomatic treatment.

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Figure 1.  Findings in patient 1. (a) Elkonyxis on the left third fingernail with multiple transverse grooves on the nail plate. (b) The patient had washboard nail on both thumb nails, and on the left index and middle fingernails. (c, d) Biopsy showed fibrinopurulent necrotic materials. [Hematoxylin and eosin stain; original magnification (c) ×40, (d) ×400]

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A 34-year-old man presented with a dome-shaped, reddish papule on the right thumb nail that had been present for one week and had been sustained by impact with the corner of a desk. The patient had been diagnosed with 20-nail dystrophy with regular pits and rough surfaces on the finger and toenails for eight years without specific treatment (Fig. 2a). A 2-mm punch biopsy was performed. Histopathology of the specimen showed necrotic tissue on the surface and increased vascular structures, collagen bundles, and inflammatory cells in the dermis that were consistent with pseudopyogenic granuloma (Fig. 2b).

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Figure 2.  Findings in patient 2. (a) Elkonyxis on the right thumb nail with 20-nail dystrophy. (b) Histopathologic findings were consistent with pseudopyogenic granuloma. (H&E stain; ×200)

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Elkonyxis is an unusual nail finding that has been rarely reported. Elkonyxis is considered as a severe fragility of the dorsal nail plate1 or a very large pit.5 Elkonyxis is differentiated from Beau’s line or onychomadesis by the presence of punched-out lesions in the nail plate. The length and width of elkonyxis suggest the extent to which the matrix is affected. The depth of the lesion suggests the extent of involvement of the nail matrix from the proximal and dorsal matrix to the distal and ventral matrix. The pathogenesis of elkonyxis is unknown, and its causes have been reported as systemic retinoid treatment3 and peritonitis.4 Other possible causes of elkonyxis include syphilis, psoriasis, Reiter’s syndrome, and trauma. In our cases, the elkonyxis had occurred after trauma in nails previously affected with washboard nail and 20-nail dystrophy, respectively, both of which are also clinical manifestations of pathologic changes in the nail matrix. The histopathology of elkonyxis demonstrated a reactive inflammation and granulation tissues that had not been revealed in previous reports.

Acknowledgment

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  2. Acknowledgment
  3. References

This work was supported by grant funding (2010-0002431, 2011-0001390) through the National Research Foundation (NRF) of Korea, which is funded by the Ministry of Education, Science and Technology, South Korea.

References

  1. Top of page
  2. Acknowledgment
  3. References
  • 1
    Tosti A, Daniel CR, Piraccini BM, Lorizzo M. Color Atlas of Nails. New York, NY: Springer, 2010: 3839.
  • 2
    Baran R, Dawber RPR. Baran and Dawber’s Diseases of the Nails and their Management. Malden, MA: Blackwell Science, 2001: 70.
  • 3
    Yung A, Johnson P, Goodfield MJ. Isotretinoin-induced elkonyxis. Br J Dermatol2005; 153: 671672.
  • 4
    Caputo R, Gelmetti C, Cambiaghi S. Severe self-healing nail dystrophy in a patient on peritoneal dialysis. Dermatology1997; 195: 274275.
  • 5
    Jadhav VM, Mahajan PM, Mhaske CB. Nail pitting and onycholysis. Indian J Dermatol Venereol Leprol2009; 75: 631633.