Onychomadesis secondary to hand-foot-and-mouth disease: report of two cases^☆, ^☆☆

Dear Editor,

Although onychomadesis secondary to hand-foot-and mouth disease (HFM) is an an uncommon clinical manifestation; it threatens parents and child caregivers. In a case series of 145 Thai patients, it occurred in 5-37% of cases, depending on the virus. ¹ HFM is more frequently caused by coxsackie virus, subtype A6, but some enterovirus and echovirus may also be involved. It is common in children below 10 years of age, ² and manifests with flu-like symptoms (fever, limphadenomegaly, dizziness, vomiting and discomfort) associated to canker sores in the oral mucosae and bullae on the hands and feet. Oral-faecal transmission for 30 after the resolution of symptoms and skin lesions. Nail changes often observed in HFM are Beau lines, leukonychia, and onychomadesis. ³ Beau lines are white transverse grooves, resulting from temporary stop nail plate formation. ³ Onychomadesis may be a more severe form of this commitment, when nail growth is interrupted for one or two weeks, resulting in detachment of the nail plate from nail bed. The new nail grows without connection to the older one, leading to splitting and detachment of the older nail. It has been proposed that this alteration may be caused by toxic direct action of the virus in the matrix or by the inflammation secondary to maceration of digital bullae. ⁴ According to a case series, ¹ onychomadesis is more usual in HFM caused by Coxsackie A6 virus than other viruses. Nevertheless, a Spanish study, ⁵ which investigated an onychomadesis outbreak (311 cases) showed high frequency of HFM as a possible cause (60%), a finging confirmed by identifying coxsackie and enterovirus in faecal samples ⁵ Obs. adicionar referiencia subscrito Treatment is symptomatic because it is a self-limited disease with rare sequelae. We present a 3-year-old male patient (Fig. 1) and a 7-year-old female patient (Figs. 2 and 3)with onychomadesis secondary to HFM, with history of flu-like symptoms, followed up by oral and acral lesions. Nail changes appeared around 14 days after the symptoms began in the first case and 10 days in the second one. They had complete resolution of the nail alterations, with no specific treatment and no sequelae. Parent counselling about this manifestation is necessary to avoid untimely therapeutics and unnecessary emergency consultations.

Figure 1
Hands from patient with 3 years old, showing Beau lines in almost every nail, and onychomadesis in second (both sides) and fourth finger.

Figure 2
Right hand from the 7-year-old showing onychomadesis in third and fourth fingers.

Figure 3
Details from first finger of the right hand from the 7-year-old patient, showing detachment of the previous nail from the newer one.

• ☆
  How to cite this article: Ocanha-Xavier JP, Xavier Jr JCC. Onychomadesis secondary to hand-foot-and-mouth disease: report of two cases. An Bras Dermatol. 2020;95:266-8.
• ☆☆
  Study conducted at the Private Clinic Tiradentes, Vila Mendonça Araçatuba, SP, Brazil.
• Financial support
  None declared.

References

• ¹
  Wei SH, Huang YP, Liu MC, Tsou TP, Lin HC, Lin TL, et al. An outbreak of coxsackievirus A6 hand, foot, and mouth disease associated with onychomadesis in Taiwan, 2010. BMC Infect Dis. 2011;11:346.
• ²
  Kimmis BD, Downing C, Tyring S. Hand-foot-and-mouth disease caused by coxsackievirus A6 on the rise. Cutis. 2018;102:353-6.
• ³
  Mortada I, Mortada R, Bazzal MA. Onychomadesis in a 9-month-old boy with hand-foot-mouth disease. Int J Emerg Med. 2017;10:26.
• ⁴
  Akpolat ND, Karaca N. Nail changes secondary to hand-foot-mouth disease. Turk J Pediatr. 2016;58:287-90.
• ⁵
  Davia JL, Bel PH, Ninet VZ, Bracho MA, Candelas FG, Salazar A, et al. Onychomadesis outbreak in Valencia, Spain associated with hand foot, and mouth disease caused by enteroviruses. Pediatr Dermatol. 2011;28:1-5.

Publication Dates

• Publication in this collection
  06 July 2020
• Date of issue
  May-Jun 2020

History

• Received
  5 Mar 2019
• Accepted
  13 June 2019
• Published
  20 Feb 2020