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 Table of Contents  
Year : 2019  |  Volume : 39  |  Issue : 2  |  Page : 95-97

Anonychia multiplex: methotrexate induced?

Department of Dermatology, Venereology and Leprosy, Government Medical College, Amritsar, Punjab, India

Date of Submission26-Jan-2019
Date of Acceptance20-May-2019
Date of Web Publication03-Jul-2019

Correspondence Address:
Lovleen Kaur
Department of Dermatology, Venereology and Leprosy, Government Medical College, Amritsar, Punjab 143001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejdv.ejdv_2_19

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Psoriasis is a chronic systemic inflammatory disease primarily involving skin, nails, and articular system with associated disease-related comorbidities including type 2 diabetes mellitus and metabolic syndrome. In the past, studies had hypothesized that rapid nail growth of psoriatic nail plate with associated parakeratosis does not allow the fungus to lodge in the nail keratin, thereby the incidence of onychomycosis should have been low in nail psoriasis. However, current studies mention that psoriatic nails are predisposed to secondary onychomycosis, but the end result of manifesting as anonychia multiplex of these two coexistent nail diseases, further complicated by methotrexate, has not been reported in the literature till date. We hereby, report a case of anonychia multiplex of psoriatic nails with coexisting onychomycosis, probably induced by methotrexate-related immunosuppression, for its rarity.

Keywords: anonychia, anonychia multiplex, methotrexate, nail psoriasis, onychomycosis, psoriasis, secondary onychomycosis

How to cite this article:
Mahajan BB, Kaur L, Singla C, Chojer P, Kumar V. Anonychia multiplex: methotrexate induced?. Egypt J Dermatol Venerol 2019;39:95-7

How to cite this URL:
Mahajan BB, Kaur L, Singla C, Chojer P, Kumar V. Anonychia multiplex: methotrexate induced?. Egypt J Dermatol Venerol [serial online] 2019 [cited 2020 Jan 25];39:95-7. Available from: http://www.ejdv.eg.net/text.asp?2019/39/2/95/262034

  Introduction Top

Psoriasis is a chronic systemic inflammatory disease involving skin, nails, and joints either alone or in combination, often associated with other comorbidities including diabetes mellitus and metabolic syndrome [1]. Lifetime incidence of nail involvement in psoriasis is estimated to range from 80 to 90% [2]. The results of studies in the literature are conflicting, regarding the risk of occurrence of onychomycosis in nails already affected by psoriasis. A case of anonychia multiplex of psoriatic nails with concomitant onychomycosis induced by methotrexate is being reported, for its rare presentation.

  Case report Top

A 75-year-old male patient presented to the Dermatology Outpatient Department in a Tertiary Care Hospital with anonychia of right second toenail since one month and third toenail since three days. He had history of chronic plaque psoriasis since 3 years and nail changes since 9 months, for which he was taking 15 mg weekly oral methotrexate on regular basis, which resulted in remission of skin lesions but did not prevent and remit the nail disease. The patient also had associated diabetes. On examination, few erythematous hyperkeratotic plaques with silvery scales on dorsum of right foot and shin and a single guttate lesion on dorsum of left foot were present. Along with anonychia of right second and third toenails, a small triangular ulcer with moist erythematous floor was apparent on the nail bed of right third toe ([Figure 1] and [Figure 2]). Rest of the toenails showed yellowish discoloration. Further inspection of second and third interdigital space of right foot revealed erosions with maceration and glistening white plaques with fringed edges, clinically suggesting interdigital flexural candidiasis ([Figure 3]). This was completely overlooked and unnoticed by the patient. All the fingernails had manifestations of nail psoriasis including multiple irregularly arranged pits, Beau’s lines and splinter hemorrhages ([Figure 4]). In addition, left little fingernail and bilateral thumb nails had golden-yellow discoloration, lost cuticle and erosions at the distolateral end of the nail plate ([Figure 5]). Mycological examination of nail clippings and skin scrapings from toe web spaces revealed budding yeast cells with growth of Candida albicans on fungal culture. Apart from raised blood sugar, all investigations were normal. The patient was educated about the importance of inspecting his feet daily, drying the feet and web spaces properly and avoiding occlusive socks and ill-fitting shoes causing repetitive trauma. Oral and topical antifungal drugs in the form of oral fluconazole 150 mg twice weekly and topical luliconazole cream 1% were given for three weeks and treatment for diabetes was revised as per medical consultation.
Figure 1 Erythematous scaly plaque on the dorsum of right foot with anonychia of right second and third right toenails.

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Figure 2 Bright red triangular ulcer over the nail bed of third toe with ragged cuticle and apparent anonychia.

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Figure 3 Macerated whitish plaque with erosions and fringed edges in the second interdigital space of right foot.

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Figure 4 Left hand nails with coarse pits, beau’s lines and nail plate erosion with golden-yellow discoloration of fifth fingernail.

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Figure 5 Bilateral thumb nails with beau’s lines, nail plate erosions and discoloration, and missing cuticle.

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  Discussion Top

Onychomycosis is reported in up to 47% of patients with psoriasis [3]. The compact orthokeratosis in a normal nail plate provides a physical barrier against penetration by microorganisms [4]. Owing to compromised nail unit barrier, this protection is lost in nail psoriasis. Moreover, the distal onycholysis in nail psoriasis may predispose the moist subungual space to easy colonization by various microorganisms [5]. In contrast; the high turnover rate with faster elimination of the distal nail plate in conjunction with increased antimicrobial peptides such as psoriasis may provide protection against such microorganisms [6],[7].

In a study by Zisova et al. [8], nail psoriasis coexisting with candidal onychomycosis had higher NAPSI scores than nail psoriasis alone, probably because candidal invasion of nail plate may act as a type of Koebner’s phenomenon which could trigger and aggravate nail psoriasis. Moreover, the indiscriminate use of topical corticosteroids in nail psoriasis causes local immunosuppression, hence predispose the psoriatic nail to develop onychomycosis. Concerning methotrexate, there is evidence that it considerably retards the nail growth owing to its antimitotic effects. In addition, its immunosuppressive effect may create an ideal background for easy invasion of nail keratin by Candida albicans [9]. This case shows correlation of psoriasis with type 2 diabetes and association of psoriatic nails with candidal onychomycosis ultimately leading to anonychia multiplex. Oral methotrexate in this case could not result in resolution of nail psoriasis even after 2 years of regular therapy. Rather, methotrexate might have further aggravated the nail disease by retarding the nail growth and thereby facilitating the easier invasion of Candida spp. in the nail plate. Immunosuppression by methotrexate would have further added to the ultimate causation of anonychia multiplex. Thus, onychomycosis in patients of psoriasis should alarm the treating physician and should be treated promptly. This will prevent koebnerization, as consequences can be grave, resulting in severe onycholysis and eventually anonychia causing significant morbidity to the patient. Owing to immunosuppression, caused by methotrexate and topical corticosteroids, their use in patients with associated comorbidities like diabetes mellitus should be carefully monitored.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Gisondi P, Ferrazzi A, Girolomoni G. Metabolic comorbidities and psoriasis. Acta Dermatovenerol Croat 2010; 18:297–304.  Back to cited text no. 1
Samman PD, Fenton DA. The nails in disease. 5th ed. Oxford: Butterworth-Heinemann Ltd; 1994.  Back to cited text no. 2
Shemer A, Trau H, Davidovici B, Grunwald MH, Amichai B. Onychomycosis in psoriatic patients − rationalization of systemic treatment. Mycoses 2010; 53:340–343.  Back to cited text no. 3
Elewski BE. Onychomycosis: pathogenesis, diagnosis, and management. Clin Microbiol Rev 1998; 11:415–429.  Back to cited text no. 4
Szepietowski JC, Salomon J. Do fungi play a role in psoriatic nails? Mycoses 2007; 50:437–442.  Back to cited text no. 5
Dawber R. Fingernail growth in normal and psoriatic subjects. Br J Dermatol 1970; 82:454–457.  Back to cited text no. 6
Dorschner RA, Lopez-Garcia B, Massie J, Kim C, Gallo RL. Innate immune defense of the nail unit by antimicrobial peptides. J Am Acad Dermatol 2004; 50:343–348.  Back to cited text no. 7
Zisova L, Valtchev V, Sotiriou E, Gospodinov D, Mateev G. Onychomycosis in patients with psoriasis − a multicentre study. Mycoses 2012; 55:143–147.  Back to cited text no. 8
Dawber RP. The effect of methotrexate, corticosteroids and azathioprine on fingernail growth in psoriasis. Br J Dermatol 1970; 83:680–683.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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