Case and Research Letter
Idiopathic Acquired Leukonychia Totalis of the Fingernails in a Child Treated Successfully with Zinc and Amino Acid Supplementation
Leuconiquia totalis idiopática, adquirida de las uñas de las manos tratada con éxito mediante suplementos de zinc y aminoácidos
P. D'Souza
, U. Khanna, T. Kumar Dhali, S. Chowdhry
Corresponding author
Department of Dermatology, ESIPGIMSR Basaidarapur, New Delhi 15, India
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D'Souza, U. Khanna, T. Kumar Dhali, S. Chowdhry" "autores" => array:4 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "D'Souza" "email" => array:1 [ 0 => "paschaldsouza@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "U." "apellidos" => "Khanna" ] 2 => array:2 [ "nombre" => "T." "apellidos" => "Kumar Dhali" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Chowdhry" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Dermatology, ESIPGIMSR Basaidarapur, New Delhi 15, India" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Leuconiquia totalis idiopática, adquirida de las uñas de las manos tratada con éxito mediante suplementos de zinc y aminoácidos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 975 "Ancho" => 1300 "Tamanyo" => 182330 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Idiopathic acquired leukonychia totalis of the fingernails in a 10-year old child.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Leukonychia is whitening of the nail plate. In 1919, Mees first described leukonychia in arsenic intoxication.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Baran classified leukonychia into true, apparent, and pseudo-leukonychia. True leukonychia can be acquired or inherited, and based on the distribution of white blotches, can be further subclassified as leukonychia punctata, leukonychia striata, leukonychia partialis, or leukonychia totalis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> There are very few reported cases of idiopathic acquired leukonychia totalis<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and we report the present case to demonstrate this uncommon clinical entity in a 10-year-old boy and his response to micronutrient supplementation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 10-year-old boy presented at our clinic with porcelain white finger nails that he had had since 4 years of age. Leukonychia totalis and leukonychia striata were seen on the fingernails, with leukonychia partialis in both the thumbnails (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). A detailed history demonstrated progression from leukonychia partialis to striata and totalis over the years. The strength of the nail plate was normal. Pressure over the nail plate caused no fading of the leukonychia, suggesting nail matrix origin and ruling out Muehrcke's lines (apparent leukonychia striata), a common clinical differential diagnosis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> His hair, eyes, teeth, and the remainder of the cutaneous examination were normal. There was no clinical evidence of malnutrition, alopecia areata, psoriasis, or lichen planus. The patient gave no history of preceding illness, surgery, trauma, chemical exposure and drug intake, including herbal medicines. The patient was born out of a nonconsanguinous marriage and there was no family history of leukonychia. Repeated cultures and microscopic examination of the nail clippings with 10% potassium hydroxide were negative. All the routine investigations, including serum proteins, liver function tests, serum calcium, and zinc levels were within normal limits. With the aforementioned clinical and laboratory assessment a diagnosis of idiopathic leukonychia partialis to totalis of the fingernails was established. The patient's parents did not consent to a nail biopsy. The boy was started orally on Zinc sulfate 137.5<span class="elsevierStyleHsp" style=""></span>mg (containing 50<span class="elsevierStyleHsp" style=""></span>mg elemental zinc) capsule once daily, along with a single daily capsule of 8 essential amino acids and vitamins A, B complex, C, D, and E (containing 18.3<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-leucine, 5.9<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-isoleucine, 25<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-lysine hydrochloride, 5<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-phenylalanine, 4.2<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-threonine, 6.7<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-valine, 5<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-tryptophan, 18.4<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">dl</span>-methionine, 2500 IU vit A, 200 IU vit D, 5<span class="elsevierStyleHsp" style=""></span>mg vit B1, 3<span class="elsevierStyleHsp" style=""></span>mg vit B2, 25<span class="elsevierStyleHsp" style=""></span>mg vit B3, 5<span class="elsevierStyleHsp" style=""></span>mg vit B5, 1.5<span class="elsevierStyleHsp" style=""></span>mg vit B6, 2.5<span class="elsevierStyleHsp" style=""></span>mg vit B12, 0.75<span class="elsevierStyleHsp" style=""></span>mg folic acid, 40<span class="elsevierStyleHsp" style=""></span>mg vit C, and 7.5 IU vit E). Two monthly follow-ups showed serial improvement at each visit, and complete resolution of the leukonychia was observed at the end of 7 months (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The treatment was continued for 3 months after resolution of the leukonychia, and there was no relapse in the 6 months after treatment was discontinued. The patient is presently monitored.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Leukonychia is the most common chromatic abnormality of the nail; however the physiologic mechanisms causing it are not entirely clear and Newton's theorem (i.e. a surface appears white when it reflects the radiation of visible light), has been proposed to explain leukonychia. In true leukonychia there is abnormal matrix keratinization, with persistent parakeratosis and keratohyalin granules in the nail plate, which might play a role in the modification of the light reflection by the ungual plates.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Baran classified leukonychia into the following 3 primary types: (1) true leukonychia, where in the nail plate involvement originates in the matrix; (2) apparent leukonychia, in which the pathology lies in the subungual tissue; and (3) pseudo-leukonychia, which is due to keratin granulations, as seen in superficial white onychomycosis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Inherited leukonychia can be presented as an isolated condition or as one of the several other reported syndromes. There is an autosomal, dominantly inherited syndrome in which leukonychia occurs in combination with kidney stones and sebaceous cysts, with sensory-neural deafness and knuckle pads, which is known as the Bart-Pumphrey syndrome.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Popular lay media claim that the etiology of leukonychia is due to calcium and/or zinc deficiency. However, no studies are available in the scientific literature to support or refute these claims.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Acquired leukonychia has been reported due to trauma, drugs such as chemotherapeutic agents (e.g., anthracyclines, cyclophosphamide, vincristine, cyclosporine, fluorouracil, and methotrexate), and systemic or local infections (e.g., typhoid fever, hepatic cirrhosis, ulcerative colitis, leprosy, and recently due to selenium deficiency in Crohn's disease).<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5,6</span></a> In children, increased requirements for macro- and micronutrients during the growing years might not be met adequately through routine meals. This deficiency could not be reflected in their serum values; however it could lead to subtle manifestations of nutritional deficiencies such as leukonychia, as in the present case. Clinicians should consider oral supplementation of relevant micronutrients in cases of acquired leukonychia, even in patients for whom serum levels do not reveal any evidence of nutritional deficiency. To the best of our knowledge, only 7 cases of idiopathic acquired leukonychia totalis have been reported to date.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,7–12</span></a> Our case is the eighth addition to the list; furthermore, it is the first case of acquired leukonychia totalis of the fingernails in which a successful resolution following therapy has been reported.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 975 "Ancho" => 1300 "Tamanyo" => 182330 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Idiopathic acquired leukonychia totalis of the fingernails in a 10-year old child.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 975 "Ancho" => 1300 "Tamanyo" => 171314 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Six-month follow-up showing near complete resolution of the leukonychia.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Mees Een verschijnsel bij polyneuritis arsenicosa" ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Nederl Tijdschr Geneesk" "fecha" => "1919" "volumen" => "1" "paginaInicial" => "391" "paginaFinal" => "396" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Baran and Dawber's diseases of the nails and their management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R.D.R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 86 | 30 | 116 |
| 2024 September | 113 | 42 | 155 |
| 2024 August | 141 | 86 | 227 |
| 2024 July | 119 | 43 | 162 |
| 2024 June | 117 | 33 | 150 |
| 2024 May | 105 | 32 | 137 |
| 2024 April | 109 | 48 | 157 |
| 2024 March | 128 | 37 | 165 |
| 2024 February | 121 | 31 | 152 |
| 2024 January | 160 | 39 | 199 |
| 2023 December | 227 | 21 | 248 |
| 2023 November | 222 | 32 | 254 |
| 2023 October | 290 | 43 | 333 |
| 2023 September | 223 | 35 | 258 |
| 2023 August | 233 | 23 | 256 |
| 2023 July | 241 | 43 | 284 |
| 2023 June | 208 | 24 | 232 |
| 2023 May | 253 | 29 | 282 |
| 2023 April | 313 | 21 | 334 |
| 2023 March | 242 | 30 | 272 |
| 2023 February | 183 | 29 | 212 |
| 2023 January | 157 | 32 | 189 |
| 2022 December | 128 | 35 | 163 |
| 2022 November | 145 | 49 | 194 |
| 2022 October | 161 | 48 | 209 |
| 2022 September | 153 | 48 | 201 |
| 2022 August | 157 | 47 | 204 |
| 2022 July | 199 | 40 | 239 |
| 2022 June | 209 | 44 | 253 |
| 2022 May | 208 | 37 | 245 |
| 2022 April | 247 | 48 | 295 |
| 2022 March | 194 | 59 | 253 |
| 2022 February | 202 | 39 | 241 |
| 2022 January | 292 | 51 | 343 |
| 2021 December | 160 | 57 | 217 |
| 2021 November | 758 | 49 | 807 |
| 2021 October | 189 | 59 | 248 |
| 2021 September | 142 | 34 | 176 |
| 2021 August | 164 | 29 | 193 |
| 2021 July | 130 | 32 | 162 |
| 2021 June | 126 | 29 | 155 |
| 2021 May | 138 | 36 | 174 |
| 2021 April | 308 | 117 | 425 |
| 2021 March | 187 | 31 | 218 |
| 2021 February | 97 | 33 | 130 |
| 2021 January | 91 | 30 | 121 |
| 2020 December | 74 | 31 | 105 |
| 2020 November | 54 | 25 | 79 |
| 2020 October | 59 | 16 | 75 |
| 2020 September | 67 | 23 | 90 |
| 2020 August | 58 | 22 | 80 |
| 2020 July | 59 | 18 | 77 |
| 2020 June | 52 | 35 | 87 |
| 2020 May | 44 | 19 | 63 |
| 2020 April | 30 | 21 | 51 |
| 2020 March | 24 | 23 | 47 |
| 2020 February | 4 | 4 | 8 |
| 2020 January | 4 | 5 | 9 |
| 2019 December | 4 | 18 | 22 |
| 2019 November | 4 | 24 | 28 |
| 2019 October | 0 | 24 | 24 |
| 2019 September | 0 | 13 | 13 |
| 2019 August | 4 | 23 | 27 |
| 2019 July | 4 | 17 | 21 |
| 2019 June | 5 | 15 | 20 |
| 2019 May | 5 | 22 | 27 |
| 2019 April | 2 | 23 | 25 |
| 2019 March | 2 | 26 | 28 |
| 2019 February | 0 | 8 | 8 |
| 2019 January | 5 | 12 | 17 |
| 2018 December | 0 | 5 | 5 |
| 2018 November | 0 | 14 | 14 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 6 | 0 | 6 |
| 2018 April | 0 | 2 | 2 |
| 2018 March | 1 | 1 | 2 |
| 2018 February | 17 | 2 | 19 |
| 2018 January | 44 | 7 | 51 |
| 2017 December | 47 | 6 | 53 |
| 2017 November | 23 | 6 | 29 |
| 2017 October | 29 | 5 | 34 |
| 2017 September | 16 | 9 | 25 |
| 2017 August | 24 | 8 | 32 |
| 2017 July | 28 | 3 | 31 |
| 2017 June | 26 | 40 | 66 |
| 2017 May | 9 | 7 | 16 |
| 2017 April | 10 | 13 | 23 |
| 2017 March | 9 | 15 | 24 |
| 2017 February | 6 | 12 | 18 |
| 2017 January | 6 | 5 | 11 |
| 2016 December | 11 | 19 | 30 |
| 2016 November | 10 | 22 | 32 |
| 2016 October | 14 | 9 | 23 |
| 2016 September | 0 | 5 | 5 |
| 2016 August | 0 | 2 | 2 |
| 2016 July | 10 | 4 | 14 |
| 2016 June | 12 | 1 | 13 |
| 2016 May | 11 | 2 | 13 |
| 2016 April | 18 | 3 | 21 |
| 2016 March | 7 | 2 | 9 |
| 2016 February | 11 | 1 | 12 |
| 2016 January | 10 | 6 | 16 |
| 2015 December | 18 | 9 | 27 |
| 2015 November | 1 | 4 | 5 |
| 2015 October | 0 | 3 | 3 |
| 2015 September | 0 | 4 | 4 |
| 2015 August | 0 | 7 | 7 |
| 2015 July | 6 | 4 | 10 |
| 2015 June | 12 | 11 | 23 |
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