Cutaneous T-cell lymphoma - Nail and Distal Digit
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Synopsis
Nail changes are common in patients with CTCL, especially those with Sézary syndrome, and typically affect more than one nail. In many cases, changes affect all 20 nails. At times, the nail changes are due to treatments of CTCL and not to the disease itself. For example, Beau lines have been observed with chemotherapy, and melanonychia was seen with psoralen plus ultraviolet A (PUVA) therapy.
In a retrospective study of 83 patients with Sézary syndrome, 36 patients (43.4%) were found to have nail changes. Nail thickening, nonspecific nail dystrophy, nail plate yellowing, and subungual hyperkeratosis were among the most common nail findings (42%-58%). Other nail changes were onycholysis, nail plate ridging, and splinter hemorrhages, seen in 17%-19% of patients. Beau lines and onychomadesis were seen in 8% of patients. In another study, 52.9% (45 of 85) of patients with Sézary syndrome who had keratoderma had positive potassium hydroxide (KOH) tests under microscopy on skin scrapings. Therefore, some of these nail changes may be attributable to onychomycosis. Paronychia was frequently reported in another study of 19 patients with Sézary syndrome (63.2%).
Small case series and case reports have described nail discoloration and thickening, onycholysis, crumbling, subungual hyperkeratosis, anonychia, onychomadesis, and splinter hemorrhages in patients with MF. In a retrospective study of 60 patients with biopsy-proven MF, 18 (30%) had nail changes. The most common nail findings were longitudinal ridging, nail plate thickening, nail fragility, and leukonychia.
Codes
ICD10CM:C84.A0 – Cutaneous T-cell lymphoma, unspecified, unspecified site
SNOMEDCT:
400122007 – Primary cutaneous T-cell lymphoma
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
Differential diagnosis of the nail changes of CTCL:- Psoriasis – Nail changes include the oil-drop sign, onycholysis, subungual hyperkeratosis, splinter hemorrhages, and nail pits.
- Atopic dermatitis – Eczema involving the nail folds may lead to nail ridging, coarse pitting, and other dystrophic changes secondary to inflammation of the underlying matrix.
- Onychomycosis
- Pityriasis rubra pilaris – Follicular-based scaly papules with an orange hue become confluent to form plaques. Palms have an orange-hued keratoderma. Nails display subungual hyperkeratosis and thickening.
- Reactive arthritis – Keratoderma blenorrhagicum and nail involvement are common findings. Paronychia, onycholysis, ridging, splitting, elkonyxis (loss of nail plate substance above the lunula only), a brown-red discoloration, and subungual hyperkeratosis may be seen.
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Management Pearls
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Therapy
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Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.Subscription Required
References
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Last Reviewed:07/15/2020
Last Updated:02/14/2022
Last Updated:02/14/2022
Cutaneous T-cell lymphoma - Nail and Distal Digit
See also in: Overview