Types of nail problems in alopecia
Alopecia areata (AA) is a immune mediated, disease presenting with non-cicatricial alopecia occurring in a circumscribed or generalized pattern. Apart from hair, abnormalities of nails and eyes have been reported specially in more severe varieties like alopecia totalis and universalis. Nail involvement in AA may either precede or follow development of alopecia patches. Nail changes may persist for a long period of time after complete hair regrowth.
Despite untiring efforts by medical researchers in the field of alopecia areata, the exact causes of the disease are still largely unknown, and the causes of nail changes remain obscure. However, it seems likely that because the nails are similar in structure and growth to hair follicles, that the nails are targeted by the same type of inflammatory cells that target hair follicles in alopecia areata. Nail changes in alopecia areata may involve all, some, or just one of the nails. The aberrant nail changes as seen in alopecia areata patients include the following:
• Nail pitting is the most commonly seen abnormality and represents irregular keratinization in the nail matrix. When an inflammatory condition affects the nail matrix keratin is formed abnormally. This abnormal keratin detaches itself from the nail plate leaving behind punctuated depressions or pits in the nail plate.
• Longitudinal ridging or striations can also be found and are probably a result of mild disruption of the nail matrix which produces the nail plate.
• Koilonychia is represented by transverse and longitudinal concavity of the nail, resulting in a "spoon-shaped" nail. The spoon-shaped, concave nails of koilonychia commonly occur as a result of thinning and softening of the nail plate.
• Onychorrhexis are brittle nails, which often split vertically, peel and/or have vertical ridges.
• Spotting of the lunula, the white half-moon shaped portion often seen through the nail plate.
• Onycholysis is the distal (away from the point of attachment at the root) separation of the nail plate from the underlying nail bed.
• Onychomadesis is the proximal (close to the nail root) separation of the nail plate from the nail bed, which typically results in shedding of the nail. The precipitating event causes complete cessation of nail matrix activity.
• Periungual erythema or redness of the skin around the nail may be present in patients experiencing active inflammation in the nail matrix.
• Anonychia (absence of nails) and scarring are not seen.
Fragments of nail keratin can be removed and observed by using both light and electron microscopic techniques. Documentation of such research shows that most of the nail changes seen in alopecia areata have been found to be related to changes within the proximal matrix. The extent of disease seems to be maximum within the proximal matrix, minor in the distal matrix and negligible in the nail bed, with the subungual (beneath the nail) keratin being largely preserved.
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