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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 53-55

Median canaliform dystrophy of thumb and great toe nails in an 8 years old boy


Department of Skin and VD, MGIMS, Sewagram, Maharashtra, India

Date of Submission26-Aug-2019
Date of Acceptance21-Sep-2019
Date of Web Publication24-Dec-2019

Correspondence Address:
Dr Sonia P Jain
Department of Skin and VD, MGIMS, Sewagram, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_88_19

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  Abstract 


Median canaliform dystrophy is a rare nail disorder characterized by midline longitudinal ridging or splitting with canal formation in the nail plate of one or both the nails of the thumbs. It is an acquired condition that mimicks habit-tic deformity, resulting in a temporary defect in the nail matrix and cuticle. Treatment is often prolonged and unsatisfactory. Some clinicians have used topical tacrolimus (0.1%) ointment and tazarotene (0.05%) ointment successfully. We report the case of an 8-year-old boy presenting with median canaliform dystrophy of Heller affecting nails of both the thumbs and great toes, respectively.

Keywords: Median nail dystrophy, nail matrix, Pediatric nail disorders


How to cite this article:
Jain SP, Sawant AK, Sonkusale PA. Median canaliform dystrophy of thumb and great toe nails in an 8 years old boy. Indian J Paediatr Dermatol 2020;21:53-5

How to cite this URL:
Jain SP, Sawant AK, Sonkusale PA. Median canaliform dystrophy of thumb and great toe nails in an 8 years old boy. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Jan 22];21:53-5. Available from: http://www.ijpd.in/text.asp?2020/21/1/53/273844




  Introduction Top


Median canaliform dystrophy of Heller is a rare nail disorder characterized by midline longitudinal ridging or splitting with canal formation in the nail plate. The first case was reported by Heller in 1928.[1] The condition is diagnosed clinically.[2] Mean age of occurrence is 25 years. Although the etiopathogenesis that has been proposed, is repetitive trauma to the cuticle and proximal nail fold, resulting in a temporary defect in the nail matrix, in the majority of cases, the cause is unknown.[3] Some reports have suggested a familial occurrence and consequence of taking drugs like retinoids.[4] It is an idiopathic condition and reverts back to normal after a few months or year. Habit-tic deformity should be differentiated from this condition. Self-inflicted trauma to the nail and nail bed may be associated with depressive, obsessive-compulsive, or impulse control disorders.[5] There are only a few cases reported in the Indian literature on median canaliform dystrophy of the nail.


  Case Report Top


An 8-year-old school going boy came to the dermatology outpatient department with midline depression in both the thumbnails and great toenails for the past 4 years which was causing cosmetic disfigurement as complained by the parents. Neither history of chewing of the thumbnails during stress was there nor was the child on any long-term medication. There was no history of contact with chemicals and/or any known allergens. The father denied history of having any nail disorder or psychiatric disorders in other family members. On examination, both the thumbnails showed midline longitudinal depression with multiple transverse furrows arising from the median split on either side, resembling an inverted fir-tree pattern [Figure 1]. Enlargement of the cuticle was seen. A similar deformity was seen over both the great toenails, more on the right great toe [Figure 2]. Rest of the fingernails appeared normal. Rest of the cutaneous surface was uninvolved and systemic examination was unremarkable. Potassium hydroxide mount of scrapings from the nail plate and subungual region were negative for fungal hyphae. On the basis of clinical findings, a diagnosis of median nail dystrophy of the thumb and toenails was made. Histopathology was not done because it would offer no additional benefit in treatment. The child was started on tacrolimus (0.1%) ointment and is being followed up at present.
Figure 1: Median longitudinal groove in fir-tree pattern over both thumb nails

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Figure 2: Median longitudinal groove in toe nails

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  Discussion Top


Median canaliform dystrophy is also known as solenonychia or nevus striatus unguis or dystrophia unguis mediana canaliformis.[6] It is characterized by midline or paramedian ridging or splitting with canal formation which splits toward the nail edge giving the appearance of an inverted fir-tree or Christmas tree. Thickening of the proximal nail fold, enlargement and redness of the lunula may be seen.[2] This condition is mostly symmetrical and most commonly affects the thumbs; although, other fingernails and toenails may also be involved.

It is an idiopathic acquired condition, but familial occurrence of cases was reported by Sweeney et al. in 2005.[2] It is a temporary defect in the matrix which interferes with normal nail formation.[7] The exact etiology of this condition is unknown. Intentional trauma in the form of pushing back of the cuticle and proximal nail fold has been proposed as one of the causes of median nail dystrophy.[8] Sometimes subungual skin tumors such as myxoid tumors and glomus tumors, can also cause longitudinal grooving and lifting of nail plate from nail bed.[9] Subungual tumors such as glomus tumors and papilloma form tube-like structure (solenos) distal to it while median nail dystrophy resembles a fir tree with branches pointing backward. The absence of keratinocyte adhesions within the nail matrix with dyskeratosis is responsible for the central splitting of the nail plate due to a weak tensile strength.[7]

Histopathology shows parakeratosis and accumulation of melanin within and between the nail bed keratinocytes. Habit-tic deformity, digital mucous cyst (synovial cyst), lichen striatus, Raynaud's disease, and trachyonychia were kept as differentials for this condition. The absence of skin lesions elsewhere, asymptomatic and symmetrical nature of the lesion excluded lichen striatus, Raynaud's disease and other subungual tumors as underlying causes for this nail dystrophy.

The management of median nail dystrophy is many a times challenging as no therapy is consistent with success. Opinion of a psychiatrist should be taken in patients with stressful conditions such as depression, obsessive-compulsive, or impulse-control disorders to prevent further damage to the nail. Injecting triamcinolone acetonide locally is one option, but it is extremely painful and also has certain adverse effects. Recently, the use of topical tacrolimus (0.1%) ointment has been reported in literature.[7],[10] It is effective due to its interference with the inflammatory component in this condition. Topical tazorotene (0.05%) ointment which normalizes the process of keratinization has also been used with variable success.[10]


  Conclusion Top


There are only a few published reports on median dystrophy of Heller in the Indian literature. We are reporting this case, as till date no pediatric case involving both finger and toenails having median canaliform dystrophy has been reported in the Indian literature to the best of our knowledge. This rare nail disorder is diagnosed clinically. Scientific reporting of new cases not only adds to our knowledge of nail disorders but also helps in the counseling of the patients and their anxious parents or caregivers.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Beck M, Wilkinson S. Disorders of nails: Median canaliform dystrophy. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 7th ed. Oxford: Blackwell Science; 2004. p. 54-5.  Back to cited text no. 1
    
2.
Sweeney SA, Cohen PR, Schulze KE, Nelson BR. Familial median canaliform nail dystrophy. Cutis 2005;75:161-5.  Back to cited text no. 2
    
3.
Pathania V. Median canaliform dystrophy of Heller occurring on thumb and great toe nails. Med J Armed Forces India 2016;72:178-9.  Back to cited text no. 3
    
4.
Dharmagunawardena B, Charles-Holmes R. Median canaliform dystrophy following isotretinoin therapy. Br J Dermatol 1997;137:658-9.  Back to cited text no. 4
    
5.
Kota R, Pilani A, Nair PA. Median nail dystrophy involving the thumb nail. Indian J Dermatol 2016;61:120.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Wu CY, Chen GS, Lin HL. Median canaliform dystrophy of Heller with associated swan neck deformity. J Eur Acad Dermatol Venereol 2009;23:1102-3.  Back to cited text no. 6
    
7.
Kim BY, Jin SP, Won CH, Cho S. Treatment of median canaliform nail dystrophy with topical 0.1% tacrolimus ointment. J Dermatol 2010;37:573-4.  Back to cited text no. 7
    
8.
Griego RD, Orengo IF, Scher RK. Median nail dystrophy and habit tic deformity: Are they different forms of the same disorder? Int J Dermatol 1995;34:799-800.  Back to cited text no. 8
    
9.
Avhad G, Ghuge P. Median canaliform dystrophy of Heller. Indian Pediatr 2013;50:1073.  Back to cited text no. 9
    
10.
Madke B, Gadkari R, Nayak C. Median canaliform dystrophy of Heller. Indian Dermatol Online J 2012;3:224-5.  Back to cited text no. 10
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    Figures

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