Advances in and venereology ActaDV Acta Dermato-Venereologica ActaDV for severealopecia. with redspotsthe disease, on thelunulaasapredictor of severity the reflects changes these of presence mostly presents with pitting The and trachyonychia. nail involvement iscommon inpatientsand with AA In conclusion, only bynailchanges. minimally affected was QoL Nail-related AA. severe for specific very but Red spots on the lunulawerelessfrequent (5.1%), 1 PASCH Acta DermVenereol 2018;98: 212–217 doi: 10.2340/00015555-2810 A The Netherlands.E-mail:[email protected] University Nijmegen Medical Center, PO Box 9101, NL-6500 HB Nijmegen, Corr: Acta DermVenereol 2018;98:212–217. Accepted Oct2,2017;Epubaheadofprint2017 sease; survey. Key words: alopeciaareata; quality of life; prevalence; nail di- pitting (29.7%, p were frequently most reported signs nail specific The ated. Prevalenceof nail was 64.1%. involvement inAA andtreatment historylife (QoL), andneedwereevalu of quality nail-related changes, nail specific variables, General demographicluated 256patientswith AA. tients with AA. This questionnaire-based survey eva pes, and clinical implications ofnail in pa changes tyaim of thisstudywasto determinethepresence, of patients with AA also have nail involvement. The causing temporary orUp to permanenthairloss. 46% isanimmune-mediated disease (AA) Yvonne B. M. ROEST Clinical Signs, ImpactonQualityofLifeandReview oftheLiterature Nail Involvement in Alopecia Areata: A Questionnaire-based Survey on 212 Institute of Psychology, Leiden University, Leiden, TheNetherlands in hospital-basedstudiesworldwide (3). AA mayappear incidence between0.57%and 3.8%hasbeenreported most importantnegativeprognostic factor(2). A lifetime syndrome (1).Severityof AA atonsetisperhapsthe pattern,associatednail changes,atopy, andDown hair lossbeforepuberty, apositivefamilyhistoryof AA, bald patchespersistingformorethanoneyear, onsetof time are not uncommon. Poor prognostic factors include year, first the given within any patients at of relapses but often benign. Spontaneous regrowth ofhair occurs in 80% The natural course of the disease is unpredictable, but even theentirebody(alopeciaareatauniversalis; AAU). affect the entire scalp (alopecia areata totalis; AAT), or scalp orbody(alopeciaareatafocalis; AAF), oritmay circumscribed roundorovalpatchesofhairlossonthe disease maybelimitedtooneormorediscrete,well- Department of Dermatology, Radboud University Nijmegen Medical Center, Nijmegen, and Yvonne B. M. Roest, Department of Dermatology, (370), Radboud that is characterized by non-scarring . The lopecia areata(AA)isanimmune-mediateddisease 1 = 0.008) and trachyonychia 0.008) (18.0%). and trachyonychia 1 , Henriët VAN MIDDENDORP This isan open access article under the CC BY-NC license. www.medicaljournals.se/acta CLINICAL REPORT 2 , Andrea W. M. EVERS - - - - by the same inflammatory reaction that targets that reaction fol inflammatory hair same the by structure andgrowthtohairfollicles,theyareaffected it hasbeenproposedthatbecausethenailsaresimilarin genic mechanismofnailchangesin AA isunknown,but later, and may persist even after hair regrowth. The patho may either precede the hair loss oroccur months oryears be higherinchildrenthanadults(8,11). Nailchanges than inpatientswithsevereformsof AA (9,10),andmay 8). Incidenceismuchlowerinpatientswithfocal AA (7, 46% to 9% from ranging incidence reported a with , andvitiligo(6). other auto-immunediseases,includingasthma,atopic unknown (5).Somestudieshaveshownassociationwith is suggested,althoughtheexactaetiologicalpathway factors andunderlyingautoimmuneaetiopathogenesis of hair loss in which a complex interplay between genetic Alopecia Patient Association between April 2013andOctober This studywasconductedin collaboration withtheDutch Patients MATERIALS ANDMETHODS need fortreatment. quality oflife(QoL),andtoevaluateapotentialunmet with nail involvementinpatients theimpactonAA, AA aresparse. The aimofthisstudywastoevaluate hasbeenreportedtodate(14). bed signsareuncommonandonlyonecaseofsevere but arehighlysuggestiveforthediagnosis AA (13).Nail typically seen.Redspotsonthelunulaarerarelypresent, without (8). andscarringarenot Beau’s lines,onychomadesis,andnailthinningwithor that mayincludepitting,trachyonychia,, in aclinicalpresentationofmatrix-derivednailchanges matrix isfarmoreofteninvolvedthanthenailbedresults and negligibleinthenailbed(12). The factthatthenail matrix, and are less pronounced in the distal matrix, the nailchangesin AA arefoundwithintheproximal and electronmicroscopictechniquesshowthatmostof licles in AA. Histopathologicalobservationsusinglight prevalence peaks between the 2 present with their first patch before 20 years of age (4), and at anyage,butasmany60%ofpatientswith AA will Many patientswith AA alsohavenailinvolvement, AA is a lymphocyte cell-mediated inflammatory form Studies in the field of nail changes in patients with patients in changes nail of field the in Studies Journal Compilation ©2018ActaDermato-Venereologica. 2 , Peter C. M. VAN DE KERKHOF 2 Health, Medical and Neuropsychology Unit, nd and 4 th decades of life (1). 1

and Marcel C. ­ - Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV *Patients with AA with nail involvement vs. patients with AA without nail involvement. **p for alltests. was consideredatalevelof5% (p variance (ANOVA). Statistical significance was performedwithone-way analysis of Statistical analysisofmorethan 2means ofpercentages. not includedincalculations Fisher’s exacttest.Missingvalueswere are presentedasmean were tested byunpaired t tinuous variableswithnormaldistribution were providedusingmean (SPSS 20.0, IBM Corp, Armonk, NY, USA). Descriptive statistics sequently performedusingStatisticalPackageforSocialSciences Data wereenteredinadatabaseandstatisticalanalysiswassub Statistical analysis (no impairmentofQoL)to18(maximumQoL). minors. The NPQ10scaleusedthereforehasarange from0 a carwasremovedbecausethetarget populationalsoincluded cerning theinterferenceofnailchangeswithabilitytodrive 1, and “very” “always” scoring 2 points. The question con “not” and “never”scoring 0, “sometimes”and“alittle”scoring daily life.Eachresponseisscoredfrom0to2,withthe the functional impairment caused by their nail involvement in pain intensityofnailchangesandtheother9questionsconcern with AA withnailinvolvement. The firstquestionconcernsthe patients for QoL of measurement the for unmodified used was ted tomeasureQoL inpatientswithnailpsoriasis(15). This scale scale (NPQ10),aquestionnaireprimarilydevelopedandvalida dermatologist. QoL wasassessedusingthenailpsoriasisQoL own words,andthesewerecategorizedlaterbyanexperienced If patients had other nail changes, they could report these in their present. were ofthesenailfeatures couldindicatewhich patients were illustratedwithphotographs.Basedonthesephotographs, onthelunula,andkoilonychialeukonychia, crumbling,redspots Nail signsassumedtobedue AA, i.e.pitting,trachyonychia, current andprevioustreatmentsforthenailswereassessed. thought to be attributed to AA. Also, patients experience of changes nail specific and QoL, variables, demographic general no incentivesweregiven.Itcontainedquestionsconcerning envelopes. The questionnairewascompletedanonymouslyand pation andexplainingthepurposeofstudy, andreply-paid the alopeciaassociation,togetherwithaletterinvitingpartici 2013. A questionnairewasdistributedtoall930membersof Table I. Characteristicsofpatientswith and without nail involvement and thecontrol in alopecia areata group (patternhairloss,PHL) (AA) not includedtocalculatepercentages.Con categorical variables.Missingvalueswere Frequencies andpercentageswere used for distributed numericalvalues,respectively. (range) fornormally and non-parametrically and percentages and analysed by χ by analysed and percentages and variables wererepresentedbyfrequencies Alopeciaareata universalis (AAU) Alopeciaareata totalis(AAT) Alopeciaareata focalis (AAF) Type of alopecia, Age of onset alopecia, years, mean Sex, Age, years, mean Missing Male Female n (%) n ± (%) SD -test and the results -test andthe results ± D Categorical SD. ±

standard deviation(SD)andmedian ± SD < 0.05) 149 (58.2) 42 (16.4) 65 (25.4) 25.9 48.5 3 41 (16.2) 212 (83.8) (n Patients withAA 2 or or = 256) - ± ± 16.1 13.6 SD: standard deviation. areata totalis (AAT), and alopecia areata universalis (AAU). *Results of analysis of variance (ANOVA) comparing the 3 groups: alopecia areata focalis (AAF), alopecia Table II. Characteristics of patients with nail changes divided into the 3formsofalopecia Table II. Characteristicsofpatientswithnailchanges Numberof toenails Numberof fingernails Number of nails affected, Unknown Both Toenails only Fingernailsonly Localization of nail changes, n Duration nail changes,years, mean Age of onset nail changes, years, mean 107** (65.2) 22 (13.4) 35 (21.3) 26.5 1 32 (19.6) 131 (80.4) 49.0 involvement ( Patients withAAnail ± ± 16.7 14.9 - - - - n or AAU, while 25.4% had AAF. A vast majority of re had AAF.of 25.4% majority while Avast or AAU, Tablesevere had patients had Most 74.6% I. AA: AAT The distributionofpatientcharacteristicsisshownin Patient characteristics of non-scarringalopecia. between thistypeof AA andothermorediffuse forms some patientsmightnothavebeenabletodiscriminate diffusa that considered itwas excluded because were prevalence. Also, questionnairesfrompatientswith AA and trichotillomaniawereexcludedbecauseoftheirlow from patients with cicatricial alopecia, , not beenreportedinthesepatients,whilequestionnaires PHL servedascontrols,becausenailinvolvementhas for analysis. The 30questionnairesfrompatientswith questionnaires from patients with AA that were available nail involvementwerenotcompleted,resultingin256 AA were excluded because the questions concerning (PHL; 8.7%).Fiftyquestionnairesfrompatientswith had othertypesofalopecia,mostlypatternhairloss Most patients (88.2%) had AA. Other respondents 6months,aresponserateof37.3%. were returnedwithin 347 and distributed were questionnaires 930 of Atotal Patients andcharacteristics RESULTS respondents (64.1%) had experienced nail involvement nail experienced had (64.1%) respondents spondents were female (83.8%), and a small majority of n (SD) = 164) (%) -value of AAU group vs. AAT/AAF combined, ± SD ± SD 42 (45.7) 20 (21.7) 30 (32.6) 24.9 Patients withAAwithout nail involvement ( 2 9 (10.0) 81 (90.0) 47.7 4.9 34.4 4.59 (3.4) 6.84 (3.4) 1 55 (33.7) 20 (12.3) 88 (54.0) (n All AA = 164) ± ± ± ± 8.5 15.0 11.9 17.2 Nail involvementinalopeciaareata 3.6 30.7 3.00 (1.2) 6.70 (3.9) 1 10 (29.4) 6 (17.6) 18 (53.0) (n AAF = 35) ± ± 3.2 18.2 n = 92) 9.8 29.1 3.17 (3.4) 7.00 (3.4) 1 3 (14.3) 7 (33.3) 11 (52.4) (n AAT

= 22) ± p ± 10.3 Acta DermVenereol 2018 = 0.002. 17.7 0.002 0.084 0.061 0.181 0.056 0.015 p-value* 4.9 36.4 8.20 (2.7) 6.92 (3.3) 3 42 (40.4) 6 (5.8) 56 (53.8) (n AAU = 107) ± ± 9.1 16.5 – – – 28.6 0 0 30 (100) 52.2 (n Controls 0.865 0.294 0.009 0.906 0.053 0.001 0.980 p = 30) -value* ± ±

14.1 14.7 213 - Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV a with controlgroup(patternhairloss,PHL) Table III. Nail signs in patients with alopecia areata (AA) compared universalis. AAF: alopecia areata focalis; AAT: alopecia areata totalis; AAU: alopecia areata www.medicaljournals.se/acta alopecia (Table II). changes developed,ameanof7.9yearslaterthanthe patients with AA with and without nail involvement. Nail Table IV.Nail-specificqualityofliferesults(NPQ10) patients with AA (p of groups 3 all among similar was and 7, was fingers one-third ofrespondents. The meannumberofinvolved vement of both toenails and fingernails was reported by was reportedin1outof8patientswith AA, whileinvol nails wereinvolved.Isolatedinvolvementofthetoenails (p involvement tobemorefrequentinmalesthanfemales had milderformsof AA. There wasatendencyfornail (54.3%) involvement nail without patients most while with AA withnailinvolvementhad (p AAU patients with AA (p of group any among than lower significantly is which of nailabnormalitiesinthecontrolgroupwas36.6%, at anytimeduringthecourseoftheir AA. The incidence 214 25.9 involvement. The meanageofonsethairlosswas were slightlyolderthanthosewith AA withoutnail AA was 48.5 Unclassifiable Onycholysis Brittle nails Slow growth Disappearing lunula Onychomadesis Onychoschizia Onychorrhexis Ridging Beau’s lines Koilonychia Red spots lunula Crumbling Trachyonychia Nail involvement Pitting Sign 9. I am morecrabby and irritatedbecause of my nailchanges 8. I avoid chores around the house becauseof my nail changes 7. Other people helpmeto dress myself because of my nailchanges 6. I have trouble turningthelatchkey because of my nail changes 5. I have trouble puttingon socks because of my nail changes 4. Putting onclothestakes longerthannormal because of my nail changes 3. Because of my nailchanges I have trouble performing household chores 2. Because of my nailchanges I have trouble putting onmy shoes 1. My nail changes are painful All AA vs.controls. In over half of the patients with AA, only the finger the with only patients AA, the of half over In = 0.056). The meanage ±

16.1 years without significant differences between Y. B.M.Roestetal. ±

13.6 years. Patients with nail involvement n (%) n All AA 164 (64.1) 10 (3.9) 23 (9.0) 13 (5.1) 68 (26.6) 63 (24.6) 46 (18.0) 76 (29.7) = 256 7 (2.7) 3 (1.2) 1 (0.4) 1 (0.4) 1 (0.4) 9 ( (3.5) 8 (3.1) 2 (0.8) 8 (3.1) = = 0.007). Morethan65%ofpatients 0.90), whilethemeannumberof 21 (19.6) 22 (20.6) n (%) n AAF/AAT 12 (11.2) 57 (53.3) 17 (15.9) 3 (2.8) 1 (0.9) 5 (4.7) 1 (0.9) 0 1 (0.9) 3 (2.8) 3 (2.8) 7 (6.5) 0 2 (1.9) 1 (0.9) = 107 ±

SD oftherespondentswith n (%) n AAU 107 (71.8) 16 (10.7) 12 (8.1) 47 (31.5) 41 (27.5) 34 (22.8) 59 (39.6) = 149 4 (2.7) 2 (1.3) 5 (3.4) 0 1 (0.7) 0 6 (4.0) 5 (3.4) 2 (1.3) 6 (4.0) n (%) n Controls 11 (36.6) 2 (6.7) 0 1 (3.3) 0 0 0 1 (3.3) 0 1 (3.3) 0 1 (3.3) 0 6 (20.0) 4 (13.3) 2 (6.7) 2 (6.7) = 30 = 0.002), 0.241 1.000 1.000 1.000 1.000 1.000 1.000 1.000 0.488 1.000 1.000 0.373 0.578 0.253 0.193 p 0.008 0.007 -value a - - Always Very painful – – – – 4 (2.5) – 2 (1.3) – 2 (1.3) lunula (p the on spots red for only significant differencewas this patients with AAU thaninpatientswith AAF/AAT, but with both toenail and fingernail involvement, compa involvement, fingernail and toenail both with was atendencytohigherimpairmentscoreinpatients respectively). There females, in 0.92 and males in 0.84 significant difference between sex and QoL (NPQ10 was this group was 1.40. Similar to patients with AA, putting those with AA (datanotshown). The mean NPQ10in the control patients were not significantly different from restricted inputtingonsocks. The resultsinNPQ10of separately, patientswithnailinvolvementweremost were allreportedoncein AA (n nail growth,disappearinglunula,andonychomadesis patients with AA andthecontrols.Onycholysis,slow and were reported in approximately 10%ofboth the and onychoschizia are signs of brittle nail syndrome control patients.Brittleness,splitting,onychorrhexis, reported inafewpatientswith AA, butinnoneofthe nychia (3.1%)andredspotsonthelunula(5.1%)were vely, involvement. (NPQ10was1.07,0.88,0.86,respecti toenail only or fingernail only with patients with red and mean (NPQ10). The mean NPQ10 of patients with nail changes The resultsfornail-relatedQoL areshowninTable IV Quality oflife in ratherhighpercentagesthecontrolgroup.Koilo Of these,leukonychiaandcrumblingwerealsoreported are themostcommonlyobservednailchangesin AA. PHL group. shown inTable IIIandwerecomparedwiththecontrol complete questionnaires. The reportednailsignsare returned the of 64.1% to corresponds This disease. the had been affected at time some during the course of Awith patients 164 of total AAnails their that reported Patient-reported nailchanges than amongthosewith AAF or AAT (p involved toenailswashigheramongpatientswith AAU All nailfeatureswerereportedmorefrequentlyin Pitting, crumbling,leukonychia,andtrachyonychiaPitting, p = 0.066). Lookingattheactivitiesorcomplaints = ± 0.04). SD AA scorewas0.91 10 (6.3) 11 (7.0) 28 (17.7) 26 (16.5) 18 (11.5) 24 (15.2) Sometimes A littlepainful 1 (0.6) 5 (3.2) 9 (5.7) = 1, 0.4%). Never Not painful 148 (93.7) 146 (93.0) 156 (99.4) 153 (96.8) 126 (79.7) 149 (94.3) 130 (82.3) 139 (88.5) 132 (83.5) ± 1.61. There wasno = 0.009). No data No data 98 99 99 98 98 98 98 99 98 - - - Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV NR: not reported; Prosp. prospective; Retrosp.: retrospective; Observ.: observational. *Considered normal. Table V.Literatureoverviewofnailsignsinpatientswithalopeciaareata more than 15min per day in order to improve their nails. than 5 min per day. Lessthan10%werewilling tospend their nailsperday. Mostpatientswantedtospendless patients reportedbeingwillingtospendontreatmentof be time-consuming.Fig.1showstheamountoftime fortable, and39.8%ofthepatientsassumeditwould options, 28.7%thoughtthattreatmentwouldbeuncom no confidence in the effectiveness of available treatment Furthermore, 76.9% of patients with nail changes had treatment. any justify to limited too abnormalities nail desire forsuchatreatment,while65%consideredtheir a reported percent Thirty-five treatment. have to desire received treatment in the past, they were asked about their ment of nail changes caused by AA. If patients had not complex (n experienced positivetreatmentresultswithvitaminB were notreported.Ofallmentionedtherapies,8patients ding oralcorticosteroids,methotrexate,orcyclosporine B complex(n patient. Oraltreatmentsincludedbiotin(n ointment by 2patients,andintralesionalsteroidsone chlorhexidine creambyone,anunspecifiedcream/ topical one, by ointment tar patients, 4 by mentioned ment fortheirnaildisorder. Topical corticosteroidswere nail involvement indicated having received any treat with with AA patients 164 the of Twenty-two(13.8%) Treatment ofnailchanges the controlgroup. on sockswasalsotheproblemmostoftenencountered Patients wereasked about their desire foreffective treat Unmet needs (n biotin (n and ( Longitudinal ridging Beau’s lines Trachyonychia Red spotslunula Ragged cuticle Pitting Leukonychia Distal notching Study design Nail abnormalities, % Patients, Sign Control group = 1), andpedicuretreatment(n n = 2), chlorhexidinecream(n = 1), vitaminD(n = 1), vitaminD(n n 9.0 0.8 18.0 5.1 NR 29.7 24.6 3.5 based survey Questionnaire- 64.1 This study AA Yes 256

=

8). Other systemic treatments, inclu 3.3 0 6.7 0 NR 6.7 13.3 3.3 36.6 Controls Controls NR NR 11.7 2.2 NR 33.8 * NR (children) Prosp. 46 1994 (8) Tosti etal. No 272 = = 1), vitaminE(n = 1). 1), vitaminE(n 7.8 NR 8.3 0 NR 13.9 2.7 0.8 Prosp. 19.8 1998 (11) Sharma etal. AA Yes 1000 = 1), nailhardener 26.4 NR 0 0 NR 1.9 15.1 NR NR but >26.4 Controls ) vitamin = 2),

= 1), = 1), NR NR NR NR NR NR NR NR 29.4 associative descriptive- and Transversal (16) et al.1999 Hernandez Garcia- No 110 - - - - treating theirnailabnormalities. The timepatientswithalopeciaareataarewillingto 1. spend Fig. possibly duetolackofawarenesstherapeuticoptions. low, be to appeared needs medical unmet nail-specific was onlyminimallyaffected bytheirnailchanges. The be most specific for (severe) AA. QoL in patients with AA reported mostoften,butredspotsonthelunulaappearto with AAF. Pitting,leukonychia, andtrachyonychiawere more frequentlyinpatientswith AAU thaninpatients sults showed nail involvement in most patients with AA, nail signswerereportedrelativelyfrequently, in36.6% reported inthesepatients. Also, among these controls, cluded ascontrolsbecausenailinvolvementhasnotbeen reported nailinvolvement.PatientswithPHL werein with AAF,patients the of AAU (107/149) 71.8% while vement wasreportedin53.8%(35/65)ofpatientswith invol Nail incidence. reported in determinant major a vement was reported in 64.1%. Severity of alopecia was to evaluateapotentialunmetneedfortreatment.Ourre involvement in patients with AA, the impact onQoL, and study wastoevaluatetheprevalenceandsignsofnail indicate apoorprognosticfactor(7). The aimofthis Nail changesoccurfrequentlyinpatientswith AA and DISCUSSION Among the256respondentsinthisstudy, nail invol 3 NR 2 NR NR frequent Most NR NR 10.5 2002 (5) Tan etal. Prosp. No 219 Percentage 70 10 20 30 40 50 60 rd nd 0

0-5 min 2 NR 2 28 NR (17) al. 2003 Gandhi et 2 44 9 10 Prosp. No 100 Nail involvementinalopeciaareata NR NR NR NR NR (18) al. 2006 Goh et NR 38 NR NR Prosp. No 513 5-15 min Minutes perday NR NR NR 19.5 NR (10) Prohic 2009 Halilovoc & Kasumagic- NR 24.5 3.5 1.5 Retrosp. No 200 15-30 min Acta DermVenereol 2018 NR NR (9) al. 2012 Cho et NR NR NR NR 9.7 NR NR interview Retrosp., No 287 > 30min NR NR NR 2014 (7) Ranawaka frequent Most NR NR 9 NR NR study Observ. No 290 215 - - - - Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV www.medicaljournals.se/acta absence ofnailbedsigns,such asonycholysisandsub of nailmatrixdiseasewere observedinourstudy. The controls. of 26.4% in ridges longitudinal and controls, of 15.1% 19.8% ofpatientswith AA, leukonychiawaspresentin in patientswith AA. Nail involvementwasreportedin not allreported,butitappearstobeevenhigherthan incidence of nail involvement in their control group was in AA includedacontrolgroup(11). Unfortunately, the group (36.6%). Only one other study on nail involvement incidence ofnailabnormalitiesreportedinthecontrol The relevanceofthisfactorisunderlinedbythe high may havealowthresholdforreportingabnormalities. with photographs in a questionnaire. Patients themselves nail involvement. This studyusedpatient-reporteddata that mighthaveaffected theresultsisscoringof the patientswith AAF hadnailchanges. A thirdfactor of alopecia.InthestudybyGandhietal.(17),none nail changesasariskfactorfordevelopingsevereforms Garcia-Hernandez &Rodriguez-Pichardo(16)reported a higher incidence of 49.4% in the severe forms of AA. of naildystrophy19.1%intheirwholegroup,with 11, 16,17,7).Sharmaetal.(11) reportedaprevalence AA, notonlyinthisstudy, butalsoinotherreports(8, severe with involvement ismorefrequentamongpatients of patientswithsevere AA; almost60%had AAU. Nail short periodoffollow-up.Secondly, ourgroupconsisted a during or clinic, outpatient an to visit first the of time studies reportedpoint-prevalenceofnailchangesatthe lifetime incidenceofnailchanges,whileseveralother possible explanationsforthis.Firstly, wereported the nail involvementin AA thanourstudy. There areseveral Most studiesreportedalowerincidenceorprevalenceof the diseaseasfrequentlyinpatientswithlateronset AA. with AA, nailinvolvement willoccurinthecourseof nail involvementismorepresentinchildrenpresenting ter theonsetofhairloss. This suggeststhatevenif Nail abnormalitiesdeveloped,onameanof7yearsaf previously.years 24 of mean a on diagnosed, been had specific design of our study, which included patients who AA withoutnailinvolvement. This mightbedue tothe patients with AA withnailinvolvement,andthose our study the age of onset of AA did not differ between with AA (19%)wasalsoreportedby Tosti etal.(8).In adults in than (46%) children in abnormalities nail of patients withlate-onset AA (7.1%). A higherprevalence with patients in AA early-onset than in (16.9%) file cal this study, butweremorefrequentlynotedintheclini with in AATspecified not were signs Nail or (9). AAU several clinicalcharacteristicsof216Koreanpatients on focusing study file retrospective a in lowest was 46% (Table V) (5, 7–9, 11, 16–18). Reported incidence involvement in AA intheliteraturerangesfrom9.0%to with AA. The reportedprevalenceandincidenceofnail (11/30), but significantly less frequently than in patients 216 Apart fromonepatientwith onycholysis,onlysigns Y. B.M.Roestetal. - - - were reported by Tosti etal. (8) to experience onycho specificsign forAA of the nails. Three out of 274 children leukonychia anddistalnotcchingdoesnotappeartobea However, 3.4% of controls reported the same sign. Thus, study, 3.1%ofpatientswith AA reporteddistalnotching. a new change recordedin association with AA. Inour (11) introduced terminal “V” nicks of the nail plate as al. et Sharma feature. non-specific a as found was chia leukony patients, subjects. our healthy in of Also 65% in presents which disease-specific, not is that feature et al.(19)hasshownrecentlythatleukonychiaisanail occur moreoftenin AA thanincontrols. Van der Velden longitudinal bands, and punctate leukonychia did not et al.(11) reportedthatlongitudinalridging,pigmented nail changesinallpreviousstudies(8,11, 17).Sharma Pitting andtrachyonychiawerealsothemostcommon (8.1% vs. 0.9%) than did patients with AAT and AAF. cantly higher risk of developing red spots on the lunula signifi a had AAU with Patients group. control the in fewer patientswith AA (5.1%),butnotatallreported the controls.Redspotsonlunulawerereportedby (18.0%). Bothoftheseweremorefrequentthanamong tients with AA werepitting(29.7%),andtrachyonychia nail signsthatwerereportedmostfrequentlyinpa specific The (12). AA in of site only the ungual hyperkeratosis,indicatesthatthenailmatrixis 9.9 (22).Ingeneral,nailpsoriasis ismoreextensive, , because the mean score in those patients was AA appearstobemuchless troublesomethaninnail which wassimilartothecontrols. Nailinvolvementin the QoL ofpatientswith AA withameanscoreof0.91, (15). The resultsshowalowimpactofnailchangeson nail impairmentsonQoL,developedforpsoriasis of impact the to related specifically questionnaire QoL AA. Inthisstudy, weusedtheNPQ10scale,whichisa contribution ofnailinvolvementinQoL ofpatients with no dateorscoringsystemswereavailabletoaccessthe clude questions concerning nail involvement. Therefore, and severalothers(20).Noneofthesequestionnairesin (DLQI), Skindex-16, Short Form Health Survey (SF-36), with AA, including the Dermatology Life Quality Index Many toolshavebeenusedtoassessQoL inpatients are involvedthanwhenthenailsuninvolved(21). psoriasis have a significantly lower QoL when the nails have seriouseffects on QoL. For example,patients with psoriasis orchronicdermatitis. Also, naildiseasemay to thatofotherchronicdermatologicaldiseases,suchas with lower QoL (20).Health-related QoL in AA is similar res, withgreaterextentofscalpinvolvementassociated patients with AA consistently demonstratepoorQoL sco on patients QoL. A recent systematic review showed that gical distress. The diseasecanhavedetrimentalimpact making itararesignof AA ofthenails. population, onlyonepatientreportedonychomadesis, madesis duringtheacuteonsetof AA universalis.Inour Patients with AA oftenexperience markedpsycholo ------Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV REFERENCES The authorshavenoconflictsofinterest todeclare. tion, Zoetermeer, theNetherlands. This project was funded by by the Dutch alopecia areata associa ACKNOWLEDGEMENTS may bearelevantfactorinindividualpatients. in trialson AA, becauseitspresenceandimprovement play arole.Nailinvolvementshouldnotbeoverlooked tion, sincelackofawarenesstherapeuticoptionsmay psoriasis. However, thelattercould beanunderestima unmet needfortreatmentis lower comparedwithnail involvement is limited in the majority of patients, and the predictor for severe alopecia. Impairment of QoL by nail severity ofthedisease,withredspotsonlunulaasa the reflects changes nail the of severity The nychia. common andpresentsmostlywithpittingtrachyo as measuredbyNPQ10. the muchhigherimpactnailinvolvementhasinpsoriasis, with nailpsoriasispatients(22),whichcorrelates treatment inpatientswith AA ismuchlowercompared too limited to justify any treatment. The unmet need for nails, whilemostconsideredtheirnailabnormalities patients with AA desireaneffective treatmentfortheir was consideredineffective. Approximately one-third of treatment fortheirnails.Inmostcases,this individual patientswith AA. few a only for importance major of is involvement nail changes in AA, butfromourresultsitissuggestedthat nail matrix signs could be designed and validatedfor nail on solely focusing questionnaire QoL specific more A for patients,resultinginhigherscoresontheQoL scale. handicap major a cause may which onycholysis, ample painful, and has major signs of nail bed disease, for ex 3. 2. 1. In summary, nailinvolvementinpatientswith AA is A minorityof13.7%patientswith AA receivedany Villasante Fricke AC,Miteva M.Epidemiologyandburdenof van derSteenPH,van Baar HM,HappleR,Boezeman JB, Alkhalifah A, Alsantali A, Wang E, McElwee KJ, Shapiro J. 1991; 24: 227–230. areata with diphenylcyclopropenone. J Am Acad Dermatol Perret CM.Prognosticfactorsinthetreatmentof alopecia Alopecia areata update: part I. Clinical picture, histopat 177–188, quiz 89–90. hology, and pathogenesis. 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