Traumatic Transverse Leukonychia

A 24‐year‐old white male presented with a 2‐year history of changes to his nails. He stated that the white discoloration had never completely resolved but improved from time to time with the nails appearing to “grow out normally.” He complained of intermittent tenderness at the lateral and proximal nail folds from occasional “infections” that he characterized as increased redness and pus. He worked as an administrative supervisor in a machine shop and he rarely was exposed to cutting oils. Hobbies included mechanical work on his car. The patient had a several‐year history of anxiety symptoms that caused interruption of his sleep patterns. He admitted to biting his fingernails and to tapping his fingernails repeatedly on flat surfaces like a desk on most days. He admitted to constantly picking at the proximal nail fold and hyponychium of the involved fingers. The patient did notice worsening of his fingernails during stressful periods in his life. Past medical history was otherwise negative. He denied medications including chemotherapy and underlying illnesses including thyroid disease. Review of systems was negative. There was no evidence of liver or renal disease. No history of possible arsenic exposure. Family history was negative for skin and nail disease. On physical exam, the patient appeared anxious but otherwise normal. He was directly observed tapping his nails on the armrest of the chair and picking at his nails during the exam. Patient otherwise had normal teeth, hair, and skin. On exam of the nails, multiple transverse white curvilinear bands were noted. The bands were separated by normal pink nail color (Figure 1). The proximal, distal, and lateral nail folds were noted to be slightly erythematous, frayed, and jagged (Figure 2). The cuticle was noted to be frayed and almost absent. The distal nail plate was ragged on the right nail. No frank signs of infection could be appreciated. Potassium hydroxide test was negative. The patient was referred to psychiatry to manage the anxiety symptoms. Multiple transverse bands of white discoloration noted to involve almost all nails image Close‐up view of thumbnails; notice ragged proximal, lateral, and distal nail folds and slight erythema but no frank infection image