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A Few Comments Letters to the Editor IIdiopathicdiopathic aacquiredcquired truetrue Abnormal keratinization of nail plate is a possible explanation for true leukonychia. In past, biopsy of a lleukonychia:eukonychia: A fewfew ccommentsomments toenail, having trauma-induced acquired leukonychia, revealed an abnormal parakeratotic strip in the lower 1/3rd of nail plate. Leukonychia occurs due to reflection Sir, of light by these parakeratotic cells and loss of nail plate Leukonychia is the most common dyschromia of transparency.[4] While hereditary true leukonychia nails. We would like to add on the information is persistent and resistant to treatment, it requires [1] to an interesting case reported by Arsiwala in genetic counselling to unearth other syndromes in a your journal. In most of such nail aberrations, family. Removal or treatment of a cause in acquired it is difficult to make complete diagnosis. True leukonychia may result in complete reversal of this hereditary leukonychia may be another diagnostic nail abnormality. possibility here. Variable expression and incomplete penetrance in total hereditary leukonychia have Since leukonychia is rarely associated with other been documented in past.[2] Leukonychia partialis is systemic findings, one can speculate that there will a subtle variant or phase of leukonychia totalis with be many more cases compared to anecdotal reports variable expression of same genetic defect.[2] Absence published sporadically. It is imperative to diagnose this of family history does not necessitate diagnosis rare and intriguing nail abnormality correctly because of acquired leukonychia. There have been reports leukonychia cause extensive cosmetic embarrassment documenting onset of hereditary leukonychia in to the patient. childhood, not necessarily at birth.[3] Moreover, it is highly unlikely that trauma may result in total AACKNOWLEDGMENTCKNOWLEDGMENT leukonychia in all finger nails simultaneously. While hereditary leukonychia is a rare condition and We wish to thank the patient of total leukonychia who made usually involves the entire nail, acquired type usually us search the literature for diagnosis. presents in childhood as leukonychia partialis (either punctata or transverse striae).[3] True leukonychia PPratikratik GGahalaut,ahalaut, NNitinitin MMishra,ishra, may occur as an isolated trait or it may be a marker of MMadhuradhur KantKant RRastogiastogi several clinical syndromes.[3] Department of Dermatology, Sri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India A white appearance of nails can result from whitening of the nail plate due to alterations AAddressddress fforor ccorrespondence:orrespondence: Dr. Pratik Gahalaut, or dysfunctioning of nail matrix (true 69, Silver Estate, Bareilly - 243 006, Uttar Pradesh, India. E-mail: [email protected] leukonychia); the nail bed or other underlying tissue without any matrix dysfunction (apparent RREFERENCESEFERENCES leukonychia); or when nail plate alternation 1. Arsiwala SZ. Idiopathic acquired persistent true partial to total has an external origin, for example, in leukonychia. Indian J Dermatol Venereol Leprol 2012;78:107-8. onychomycosis (pseudoleukonychia).[4,5] 2. De D, Handa S. Hereditary leukonychia totalis. Indian J Dermatol Venereol Leprol 2007;73:355-7. 3. Rodríguez-Lojo R, Del Pozo J, Sacristán F, Barja J, Depending on the extent of each nail involved, Piñeyro-Molina F, Pérez-Varela L. Leukonychia total is true leukonychia may be totalis, subtotalis, or associated with multiple pilar cysts: Report of a five- partialis (involving less than 2/3rd of nail).[4] In generation family: FLOTCH syndrome? Eur J Dermatol 2011; rd 21:484-6. subtotal leukonychia, the proximal 2/3 of the nail 4. Tuzun Y, Karakus O. Leukonychia. J Turk Acad Dermatol is white.[5] Morphologically, leukonychia partialis 2009;3:93101[about 3 p.]. Available from: http://www. may again be divided into punctate, transverse, or jtad.org/2009/1/jtad93101r.pdf. [Last accessed on 2013 [4] Mar 1]. longitudinal types. Total or subtotal leukonychia is 5. Berker DAR, Baran R. Disorders of nails. In: Burns T, usually hereditary.[6] Breathnach S, Cox N, Griffiths C, editors. Rook’s Textbook 812 Indian Journal of Dermatology, Venereology, and Leprology | November-December 2013 | Vol 79 | Issue 6 Letters to the Editor of Dermatology. 8th ed. Singapore: Wiley-Blackwell; 2010. age, sex, occupation, residential background, duration p. 65.15. and pattern of disease were recorded in case sheet 6. Tosti A, Piarccini BM. Biology of Nails and Nail Disorders. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, after obtaining written informed consent. Personal Leffell DJ, editors. Fitzpatrick’s Dermatology in General or family history of atopy, present or past history Medicine. 7th ed. New York: McGraw Hill Medical; 2008. p. 782. of hypersensitivity and other dermatological and Access this article online systemic illness was also recorded. Those with atopy, Quick Response Code: Website: hypersensitive reactions were excluded in order to www.ijdvl.com avoid false positive results. Cases were subjected to DOI: patch testing as per the standard guidelines, taking 10.4103/0378-6323.120736 all necessary precautions. Patch test series used was Indian standard series (ISS), containing 25 allergens, PMID: ***** and approved by contact and occupational dermatitis forum of India. Patch testing with conventional ISS was undertaken for convenience of getting a variety of allergens combined in a single battery. We did not PPreliminaryreliminary eexperiencexperience ofof patchpatch select any particular occupational group or a specific patient group and so did not use any specific allergen ttestingesting aatt SSrinagar,rinagar, KKashmirashmir series. Reading and grading of positivity was carried out according to International Contact Dermatitis Research Group guidelines.[3] Sir, Allergic contact dermatitis (ACD), a delayed type of Out of 85 cases patch tested, 49 were males (57.6%) hypersensitivity reaction developing in sensitized and 36 females (42.4%), with age ranging from 5 years individuals after environmental exposure to allergens, to 72 years (mean age 40.47 years ± SD 14.84), is a challenging problem with considerable morbidity as described in Table 1. 51 (60%) cases were from [1,2] and economic impact. Prevention of contact with urban and 34 (40%) from rural background [Table 1]. the incriminating allergens forms the main component The duration of illness ranged from 10 days to of management of ACD, and patch testing is a useful 10 years (mean ± SD = 28.6 ± 36.20 months). [2] tool for detecting it. The exposure to allergens and the Dermatitis of hands and feet was seen in 45 (52.9%) type of allergens included in standard patch test series cases; non-specific pattern in 27 (37.8%), air borne varies considerably from area-to-area, depending on contact dermatitis (ABCD) in 10 (11.8%), and photo the local experience.[1] ACD in 3 (3.5%) cases. We conducted the study with the aim of having Out of 85 cases patch tested, 33 (38.8%), 19 males and preliminary experience of patch testing in Kashmir, 14 females, showed positive reactions. 20 cases showed in the newly set-up contact dermatitis clinic of our positive reaction to one allergen and 13 to more than department. All consecutive clinically suspected one, giving a total of 56 reactions. Thirty-four positive cases of ACD of all age groups visiting the clinic over reactions were seen in males and 22 in females. a period of 7 months, from mid-May to mid-December Most common allergens identified were potassium 2012, were included in the study. Details regarding dichromate and nickel sulfate showing nine reactions Table 1: Age, sex, residential distribution of cases Age group Males (%) Females (%) Total (n=85) (%) Rural (%) Urban (%) ≤10 years 01 01 02 00 02 11-30 years 09 17 26 (30.59) 15 11 31-50 years 27 12 39 (45.9) 12 27 51-70 years 11 06 17 06 11 ≥71 years 01 00 01 01 00 Total (n=85) 49 (57.6) 36 (42.4) 85 (100) 34 (40) 51 (60) Average age 40.47 (±14.84 SD) Average duration of illness 28.6 (±36.20 SD) months Indian Journal of Dermatology, Venereology, and Leprology | November-December 2013 | Vol 79 | Issue 6 813 Letters to the Editor (16.1%) each. Cobalt chloride showed 6 (10.7%), The age, sex and duration of illness variables in our thiuram mix 5 (8.9%), P-phenylenediamine (PPD) study were similar to other studies.[1,2,4-7] 60% cases 4 (7.1%), and colophonium 4 (7.1%) reactions. were from urban background, probably because our hospital is located in the main city. Dermatitis of In males, the most common reactions were observed with hands and feet was the most common clinical pattern potassium dichromate showing nine reactions (26.5%), in our study, similar to some studies from India and followed by 5 (14.7%) with thiuram mix. In females, abroad[2] and different from other Indian studies where the most common allergen was nickel sulfate with ABCD is common.[7] nine reactions (40.9%), followed by 5 (22.7%) with cobalt chloride. Positive reaction exclusively in males Nearly 38.8% positive reaction in our study is similar to was seen with potassium dichromate, PPD, mercapto 32.3% by Akasya-Hillenbrand et al.;[6] however, differs mix, 2-mercaptobenzothiazole, nitrofurazone, from positive results of 63.5% by Davoudi et al.,[1] 59% lanolin alcohol, thiuram mix, black rubber mix, by Bajaj et al.,[2] 63% by Handa and Jindal[7] and 64.7% formaldehyde, and parthenolide. Positive reactions by Sudhashree et al.[8] The low positive percentage exclusive to females were due to benzocaine, nickel sulfate, and polyethylene glycol 400. No reaction was tested with ISS may be because of different exposure seen with petrolatum, paraben mix, gentamicin, epoxy patterns in our population than rest of the country. resin, p-chloro-m-cresol, and clioquinol. Overall present relevance rate was 55.4% (31 reactions out of The five most common allergens were potassium 56) and the results are summarized in Table 2.
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