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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Leukonychia is whitening of the nail plate&#46; In 1919&#44; Mees first described leukonychia in arsenic intoxication&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Baran classified leukonychia into true&#44; apparent&#44; and pseudo-leukonychia&#46; True leukonychia can be acquired or inherited&#44; and based on the distribution of white blotches&#44; can be further subclassified as leukonychia punctata&#44; leukonychia striata&#44; leukonychia partialis&#44; or leukonychia totalis&#46;<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&#46;</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&#46; Leukonychia totalis and leukonychia striata were seen on the fingernails&#44; with leukonychia partialis in both the thumbnails &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; A detailed history demonstrated progression from leukonychia partialis to striata and totalis over the years&#46; The strength of the nail plate was normal&#46; Pressure over the nail plate caused no fading of the leukonychia&#44; suggesting nail matrix origin and ruling out Muehrcke&#39;s lines &#40;apparent leukonychia striata&#41;&#44; a common clinical differential diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> His hair&#44; eyes&#44; teeth&#44; and the remainder of the cutaneous examination were normal&#46; There was no clinical evidence of malnutrition&#44; alopecia areata&#44; psoriasis&#44; or lichen planus&#46; The patient gave no history of preceding illness&#44; surgery&#44; trauma&#44; chemical exposure and drug intake&#44; including herbal medicines&#46; The patient was born out of a nonconsanguinous marriage and there was no family history of leukonychia&#46; Repeated cultures and microscopic examination of the nail clippings with 10&#37; potassium hydroxide were negative&#46; All the routine investigations&#44; including serum proteins&#44; liver function tests&#44; serum calcium&#44; and zinc levels were within normal limits&#46; With the aforementioned clinical and laboratory assessment a diagnosis of idiopathic leukonychia partialis to totalis of the fingernails was established&#46; The patient&#39;s parents did not consent to a nail biopsy&#46; The boy was started orally on Zinc sulfate 137&#46;5<span class="elsevierStyleHsp" style=""></span>mg &#40;containing 50<span class="elsevierStyleHsp" style=""></span>mg elemental zinc&#41; capsule once daily&#44; along with a single daily capsule of 8 essential amino acids and vitamins A&#44; B complex&#44; C&#44; D&#44; and E &#40;containing 18&#46;3<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-leucine&#44; 5&#46;9<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-isoleucine&#44; 25<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-lysine hydrochloride&#44; 5<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-phenylalanine&#44; 4&#46;2<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-threonine&#44; 6&#46;7<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-valine&#44; 5<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-tryptophan&#44; 18&#46;4<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">dl</span>-methionine&#44; 2500 IU vit A&#44; 200 IU vit D&#44; 5<span class="elsevierStyleHsp" style=""></span>mg vit B1&#44; 3<span class="elsevierStyleHsp" style=""></span>mg vit B2&#44; 25<span class="elsevierStyleHsp" style=""></span>mg vit B3&#44; 5<span class="elsevierStyleHsp" style=""></span>mg vit B5&#44; 1&#46;5<span class="elsevierStyleHsp" style=""></span>mg vit B6&#44; 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg vit B12&#44; 0&#46;75<span class="elsevierStyleHsp" style=""></span>mg folic acid&#44; 40<span class="elsevierStyleHsp" style=""></span>mg vit C&#44; and 7&#46;5 IU vit E&#41;&#46; Two monthly follow-ups showed serial improvement at each visit&#44; and complete resolution of the leukonychia was observed at the end of 7 months &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The treatment was continued for 3 months after resolution of the leukonychia&#44; and there was no relapse in the 6 months after treatment was discontinued&#46; The patient is presently monitored&#46;</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&#59; however the physiologic mechanisms causing it are not entirely clear and Newton&#39;s theorem &#40;i&#46;e&#46; a surface appears white when it reflects the radiation of visible light&#41;&#44; has been proposed to explain leukonychia&#46; In true leukonychia there is abnormal matrix keratinization&#44; with persistent parakeratosis and keratohyalin granules in the nail plate&#44; which might play a role in the modification of the light reflection by the ungual plates&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Baran classified leukonychia into the following 3 primary types&#58; &#40;1&#41; true leukonychia&#44; where in the nail plate involvement originates in the matrix&#59; &#40;2&#41; apparent leukonychia&#44; in which the pathology lies in the subungual tissue&#59; and &#40;3&#41; pseudo-leukonychia&#44; which is due to keratin granulations&#44; as seen in superficial white onychomycosis&#46;<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&#46; There is an autosomal&#44; dominantly inherited syndrome in which leukonychia occurs in combination with kidney stones and sebaceous cysts&#44; with sensory-neural deafness and knuckle pads&#44; which is known as the Bart-Pumphrey syndrome&#46;<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&#47;or zinc deficiency&#46; However&#44; no studies are available in the scientific literature to support or refute these claims&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Acquired leukonychia has been reported due to trauma&#44; drugs such as chemotherapeutic agents &#40;e&#46;g&#46;&#44; anthracyclines&#44; cyclophosphamide&#44; vincristine&#44; cyclosporine&#44; fluorouracil&#44; and methotrexate&#41;&#44; and systemic or local infections &#40;e&#46;g&#46;&#44; typhoid fever&#44; hepatic cirrhosis&#44; ulcerative colitis&#44; leprosy&#44; and recently due to selenium deficiency in Crohn&#39;s disease&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5&#44;6</span></a> In children&#44; increased requirements for macro- and micronutrients during the growing years might not be met adequately through routine meals&#46; This deficiency could not be reflected in their serum values&#59; however it could lead to subtle manifestations of nutritional deficiencies such as leukonychia&#44; as in the present case&#46; Clinicians should consider oral supplementation of relevant micronutrients in cases of acquired leukonychia&#44; even in patients for whom serum levels do not reveal any evidence of nutritional deficiency&#46; To the best of our knowledge&#44; only 7 cases of idiopathic acquired leukonychia totalis have been reported to date&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7&#8211;12</span></a> Our case is the eighth addition to the list&#59; furthermore&#44; it is the first case of acquired leukonychia totalis of the fingernails in which a successful resolution following therapy has been reported&#46;</p></span>"
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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
Corresponding author
paschaldsouza@yahoo.com

Corresponding author.
, U. Khanna, T. Kumar Dhali, S. Chowdhry
Department of Dermatology, ESIPGIMSR Basaidarapur, New Delhi 15, India
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        "titulo" => "Leuconiquia totalis idiop&#225;tica&#44; adquirida de las u&#241;as de las manos tratada con &#233;xito mediante suplementos de zinc y amino&#225;cidos"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Leukonychia is whitening of the nail plate&#46; In 1919&#44; Mees first described leukonychia in arsenic intoxication&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Baran classified leukonychia into true&#44; apparent&#44; and pseudo-leukonychia&#46; True leukonychia can be acquired or inherited&#44; and based on the distribution of white blotches&#44; can be further subclassified as leukonychia punctata&#44; leukonychia striata&#44; leukonychia partialis&#44; or leukonychia totalis&#46;<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&#46;</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&#46; Leukonychia totalis and leukonychia striata were seen on the fingernails&#44; with leukonychia partialis in both the thumbnails &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; A detailed history demonstrated progression from leukonychia partialis to striata and totalis over the years&#46; The strength of the nail plate was normal&#46; Pressure over the nail plate caused no fading of the leukonychia&#44; suggesting nail matrix origin and ruling out Muehrcke&#39;s lines &#40;apparent leukonychia striata&#41;&#44; a common clinical differential diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> His hair&#44; eyes&#44; teeth&#44; and the remainder of the cutaneous examination were normal&#46; There was no clinical evidence of malnutrition&#44; alopecia areata&#44; psoriasis&#44; or lichen planus&#46; The patient gave no history of preceding illness&#44; surgery&#44; trauma&#44; chemical exposure and drug intake&#44; including herbal medicines&#46; The patient was born out of a nonconsanguinous marriage and there was no family history of leukonychia&#46; Repeated cultures and microscopic examination of the nail clippings with 10&#37; potassium hydroxide were negative&#46; All the routine investigations&#44; including serum proteins&#44; liver function tests&#44; serum calcium&#44; and zinc levels were within normal limits&#46; With the aforementioned clinical and laboratory assessment a diagnosis of idiopathic leukonychia partialis to totalis of the fingernails was established&#46; The patient&#39;s parents did not consent to a nail biopsy&#46; The boy was started orally on Zinc sulfate 137&#46;5<span class="elsevierStyleHsp" style=""></span>mg &#40;containing 50<span class="elsevierStyleHsp" style=""></span>mg elemental zinc&#41; capsule once daily&#44; along with a single daily capsule of 8 essential amino acids and vitamins A&#44; B complex&#44; C&#44; D&#44; and E &#40;containing 18&#46;3<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-leucine&#44; 5&#46;9<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-isoleucine&#44; 25<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-lysine hydrochloride&#44; 5<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-phenylalanine&#44; 4&#46;2<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-threonine&#44; 6&#46;7<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-valine&#44; 5<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">l</span>-tryptophan&#44; 18&#46;4<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">dl</span>-methionine&#44; 2500 IU vit A&#44; 200 IU vit D&#44; 5<span class="elsevierStyleHsp" style=""></span>mg vit B1&#44; 3<span class="elsevierStyleHsp" style=""></span>mg vit B2&#44; 25<span class="elsevierStyleHsp" style=""></span>mg vit B3&#44; 5<span class="elsevierStyleHsp" style=""></span>mg vit B5&#44; 1&#46;5<span class="elsevierStyleHsp" style=""></span>mg vit B6&#44; 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg vit B12&#44; 0&#46;75<span class="elsevierStyleHsp" style=""></span>mg folic acid&#44; 40<span class="elsevierStyleHsp" style=""></span>mg vit C&#44; and 7&#46;5 IU vit E&#41;&#46; Two monthly follow-ups showed serial improvement at each visit&#44; and complete resolution of the leukonychia was observed at the end of 7 months &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The treatment was continued for 3 months after resolution of the leukonychia&#44; and there was no relapse in the 6 months after treatment was discontinued&#46; The patient is presently monitored&#46;</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&#59; however the physiologic mechanisms causing it are not entirely clear and Newton&#39;s theorem &#40;i&#46;e&#46; a surface appears white when it reflects the radiation of visible light&#41;&#44; has been proposed to explain leukonychia&#46; In true leukonychia there is abnormal matrix keratinization&#44; with persistent parakeratosis and keratohyalin granules in the nail plate&#44; which might play a role in the modification of the light reflection by the ungual plates&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Baran classified leukonychia into the following 3 primary types&#58; &#40;1&#41; true leukonychia&#44; where in the nail plate involvement originates in the matrix&#59; &#40;2&#41; apparent leukonychia&#44; in which the pathology lies in the subungual tissue&#59; and &#40;3&#41; pseudo-leukonychia&#44; which is due to keratin granulations&#44; as seen in superficial white onychomycosis&#46;<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&#46; There is an autosomal&#44; dominantly inherited syndrome in which leukonychia occurs in combination with kidney stones and sebaceous cysts&#44; with sensory-neural deafness and knuckle pads&#44; which is known as the Bart-Pumphrey syndrome&#46;<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&#47;or zinc deficiency&#46; However&#44; no studies are available in the scientific literature to support or refute these claims&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Acquired leukonychia has been reported due to trauma&#44; drugs such as chemotherapeutic agents &#40;e&#46;g&#46;&#44; anthracyclines&#44; cyclophosphamide&#44; vincristine&#44; cyclosporine&#44; fluorouracil&#44; and methotrexate&#41;&#44; and systemic or local infections &#40;e&#46;g&#46;&#44; typhoid fever&#44; hepatic cirrhosis&#44; ulcerative colitis&#44; leprosy&#44; and recently due to selenium deficiency in Crohn&#39;s disease&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5&#44;6</span></a> In children&#44; increased requirements for macro- and micronutrients during the growing years might not be met adequately through routine meals&#46; This deficiency could not be reflected in their serum values&#59; however it could lead to subtle manifestations of nutritional deficiencies such as leukonychia&#44; as in the present case&#46; Clinicians should consider oral supplementation of relevant micronutrients in cases of acquired leukonychia&#44; even in patients for whom serum levels do not reveal any evidence of nutritional deficiency&#46; To the best of our knowledge&#44; only 7 cases of idiopathic acquired leukonychia totalis have been reported to date&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7&#8211;12</span></a> Our case is the eighth addition to the list&#59; furthermore&#44; it is the first case of acquired leukonychia totalis of the fingernails in which a successful resolution following therapy has been reported&#46;</p></span>"
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Article information
ISSN: 00017310
Original language: English
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Idiomas
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