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
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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" => 976 "Ancho" => 1301 "Tamanyo" => 188479 ] ] "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" => 976 "Ancho" => 1301 "Tamanyo" => 188479 ] ] "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" => 976 "Ancho" => 1301 "Tamanyo" => 182609 ] ] "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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 11 | 6 | 17 |
| 2024 Octubre | 92 | 48 | 140 |
| 2024 Septiembre | 122 | 38 | 160 |
| 2024 Agosto | 163 | 66 | 229 |
| 2024 Julio | 138 | 38 | 176 |
| 2024 Junio | 127 | 49 | 176 |
| 2024 Mayo | 128 | 44 | 172 |
| 2024 Abril | 100 | 24 | 124 |
| 2024 Marzo | 99 | 32 | 131 |
| 2024 Febrero | 88 | 33 | 121 |
| 2024 Enero | 73 | 56 | 129 |
| 2023 Diciembre | 84 | 19 | 103 |
| 2023 Noviembre | 89 | 34 | 123 |
| 2023 Octubre | 82 | 26 | 108 |
| 2023 Septiembre | 74 | 34 | 108 |
| 2023 Agosto | 101 | 15 | 116 |
| 2023 Julio | 100 | 58 | 158 |
| 2023 Junio | 127 | 17 | 144 |
| 2023 Mayo | 146 | 27 | 173 |
| 2023 Abril | 87 | 16 | 103 |
| 2023 Marzo | 180 | 31 | 211 |
| 2023 Febrero | 98 | 25 | 123 |
| 2023 Enero | 92 | 48 | 140 |
| 2022 Diciembre | 80 | 38 | 118 |
| 2022 Noviembre | 23 | 35 | 58 |
| 2022 Octubre | 30 | 30 | 60 |
| 2022 Septiembre | 21 | 27 | 48 |
| 2022 Agosto | 25 | 32 | 57 |
| 2022 Julio | 21 | 32 | 53 |
| 2022 Junio | 26 | 33 | 59 |
| 2022 Mayo | 86 | 50 | 136 |
| 2022 Abril | 121 | 54 | 175 |
| 2022 Marzo | 66 | 43 | 109 |
| 2022 Febrero | 64 | 26 | 90 |
| 2022 Enero | 98 | 37 | 135 |
| 2021 Diciembre | 64 | 34 | 98 |
| 2021 Noviembre | 74 | 44 | 118 |
| 2021 Octubre | 66 | 49 | 115 |
| 2021 Septiembre | 58 | 35 | 93 |
| 2021 Agosto | 57 | 33 | 90 |
| 2021 Julio | 46 | 30 | 76 |
| 2021 Junio | 30 | 20 | 50 |
| 2021 Mayo | 34 | 23 | 57 |
| 2021 Abril | 51 | 68 | 119 |
| 2021 Marzo | 42 | 22 | 64 |
| 2021 Febrero | 70 | 31 | 101 |
| 2021 Enero | 36 | 14 | 50 |
| 2020 Diciembre | 31 | 29 | 60 |
| 2020 Noviembre | 26 | 22 | 48 |
| 2020 Octubre | 32 | 24 | 56 |
| 2020 Septiembre | 35 | 16 | 51 |
| 2020 Agosto | 26 | 27 | 53 |
| 2020 Julio | 25 | 13 | 38 |
| 2020 Junio | 36 | 42 | 78 |
| 2020 Mayo | 23 | 31 | 54 |
| 2020 Abril | 25 | 28 | 53 |
| 2020 Marzo | 24 | 23 | 47 |
| 2020 Febrero | 9 | 19 | 28 |
| 2020 Enero | 4 | 20 | 24 |
| 2019 Diciembre | 4 | 11 | 15 |
| 2019 Noviembre | 4 | 2 | 6 |
| 2019 Octubre | 0 | 5 | 5 |
| 2019 Septiembre | 0 | 11 | 11 |
| 2019 Agosto | 4 | 10 | 14 |
| 2019 Julio | 4 | 13 | 17 |
| 2019 Junio | 4 | 23 | 27 |
| 2019 Mayo | 4 | 77 | 81 |
| 2019 Abril | 2 | 51 | 53 |
| 2019 Marzo | 2 | 9 | 11 |
| 2019 Febrero | 0 | 10 | 10 |
| 2019 Enero | 3 | 0 | 3 |
| 2018 Diciembre | 0 | 1 | 1 |
| 2018 Octubre | 3 | 1 | 4 |
| 2018 Septiembre | 5 | 4 | 9 |
| 2018 Agosto | 0 | 9 | 9 |
| 2018 Julio | 0 | 8 | 8 |
| 2018 Junio | 0 | 11 | 11 |
| 2018 Mayo | 0 | 15 | 15 |
| 2018 Abril | 0 | 8 | 8 |
| 2018 Marzo | 0 | 3 | 3 |
| 2018 Febrero | 70 | 13 | 83 |
| 2018 Enero | 103 | 7 | 110 |
| 2017 Diciembre | 100 | 14 | 114 |
| 2017 Noviembre | 39 | 8 | 47 |
| 2017 Octubre | 36 | 12 | 48 |
| 2017 Septiembre | 25 | 25 | 50 |
| 2017 Agosto | 28 | 19 | 47 |
| 2017 Julio | 44 | 27 | 71 |
| 2017 Junio | 39 | 21 | 60 |
| 2017 Mayo | 43 | 14 | 57 |
| 2017 Abril | 101 | 15 | 116 |
| 2017 Marzo | 53 | 34 | 87 |
| 2017 Febrero | 24 | 14 | 38 |
| 2017 Enero | 39 | 24 | 63 |
| 2016 Diciembre | 21 | 17 | 38 |
| 2016 Noviembre | 36 | 20 | 56 |
| 2016 Octubre | 18 | 30 | 48 |
| 2016 Septiembre | 0 | 9 | 9 |
| 2016 Agosto | 0 | 18 | 18 |
| 2016 Julio | 7 | 5 | 12 |
| 2016 Junio | 11 | 14 | 25 |
| 2016 Mayo | 9 | 16 | 25 |
| 2016 Abril | 13 | 47 | 60 |
| 2016 Marzo | 5 | 27 | 32 |
| 2016 Febrero | 15 | 21 | 36 |
| 2016 Enero | 9 | 26 | 35 |
| 2015 Diciembre | 10 | 12 | 22 |
| 2015 Noviembre | 1 | 17 | 18 |
| 2015 Octubre | 0 | 1 | 1 |
| 2015 Septiembre | 0 | 28 | 28 |
| 2015 Agosto | 0 | 1 | 1 |
| 2015 Julio | 3 | 3 | 6 |
| 2015 Junio | 3 | 4 | 7 |
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