Case and Research Letter
Isotretinoin-Induced Elkonyxis
Elconixis por isotretinoína
F. Allegue
, D. González-Vilas, A. Zulaica
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Servicio de Dermatología, Hospital do Meixoeiro EOXI, Vigo, Pontevedra, Spain
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Allegue, D. González-Vilas, A. Zulaica" "autores" => array:3 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Allegue" "email" => array:2 [ 0 => "fallegue@mundo-r.com" 1 => "francisco.allegue.rodriguez@sergas.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "D." "apellidos" => "González-Vilas" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Zulaica" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital do Meixoeiro EOXI, Vigo, Pontevedra, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Elconixis por isotretinoína" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1547 "Ancho" => 2333 "Tamanyo" => 454022 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Rough and brittle surface of all the nail plates, although less evident in the fifth fingers. Oil spots and pinpoint leukonychia are visible.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Elkonyxis is a change in the nails characterized by marked fragility of the dorsal nail plate, irregular defects, loss of substance, or depressions that are larger than the pitting typical of psoriasis.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> The clinical appearance thus varies from an irregular roughness of the nail plate to perforation. Elkonyxis has only rarely been described in the medical literature. We present a case of elkonyxis secondary to treatment with isotretinoin.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 17-year-old male with no past personal or family history of interest. He had moderate inflammatory acne that had recurred after several cycles of treatment with minocycline and he was therefore started on treatment with isotretinoin at a dose of 40<span class="elsevierStyleHsp" style=""></span>mg/d. The clinical course was unremarkable, with progressive improvement in his acne, minimal xerotic changes in the skin, and mild cheilitis. Laboratory tests showed no relevant alterations. During the third month of follow-up, the patient asked us to look at what he considered to be fragile nails, which he had first noticed a month after starting treatment. He denied trauma, manual labor, concurrent pathologic disorders, or other drugs. He also denied any previous nail changes or any past personal or familial history of psoriasis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On inspection, the nail plates of all the fingernails presented various degrees of deformity, with irregular depressions, a rough surface, and brittleness (<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>). Some pitting, leukonychia, and oil spots were also visible. Mild desquamating periungual hyperkeratosis was observed and there was partial loss of the cuticle of the first nail of the right hand. No changes were observed in the toenails. The patient was offered the possibility of isotretinoin dose reduction or withdrawal, but he declined. Treatment was completed successfully and 4 months later the nails had recovered a normal appearance.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Elkonyxis is a rare nail disorder that has been reported in association with diseases such as peritonitis,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> psoriasis, syphilis, and reactive arthritis, or induced by trauma<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> or by retinoids.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,5</span></a> The etiology and pathogenesis are unclear, but alterations of keratinization of inflammatory, traumatic, or pharmacological origin have been proposed. These changes occur in the nail matrix or in the proximal nail fold, giving rise to irregularities in the nail plate.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The few histopathological studies reported show inflammation and granulation tissue.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Elkonyxis affects the proximal dorsal nail plate, over the lunula, and advances distally as the nail grows. The width and depth of the defect are directly proportional to the extent of damage to the matrix.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> It is not rare to find other associated nail abnormalities, such as leukonychia,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> median canaliform dystrophy,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> or washboard nail.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Isotretinoin is a retinoid whose therapeutic effects and undesirable cutaneous, mucosal and adnexal side effects go hand in hand and are related to the drug's action on keratinization. Our patient had no previous nail or periungual changes. The alterations appeared during treatment and disappeared after its completion. In view of the chronologic correlation, the causative role of isotretinoin would appear clear, though obviously, given the nature of the treatment, we did not attempt reintroduction. Previous reports of the association between this nail disorder and isotretinoin and another retinoid, etretinate,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,5</span></a> support this hypothesis, although we cannot exclude a chance association because isotretinoin is a very widely used drug and only very few cases have been published. As with other side effects of the retinoids, elkonyxis is a dose-dependent effect.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In contrast to the case published by Yung et al.,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> in which loss of the cuticles was reported, in our patient only partial loss of the cuticle of the right thumbnail was observed. Cuticle loss was also absent in other reports of elkonyxis secondary to trauma.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We have presented a case of elkonyxis occurring as a side effect of treatment with isotretinoin, and draw attention to this rare nail alteration, as few descriptions of this condition have been published.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Allegue F, González-Vilas D, Zulaica A. Elconixis por isotretinoína. Actas Dermosifiliogr. 2017;108:166–167.</p>" ] ] "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" => 773 "Ancho" => 1166 "Tamanyo" => 89423 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Brittle appearance of the nail of the left index finger, with a central depression larger than that seen in pitting.</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" => 1547 "Ancho" => 2333 "Tamanyo" => 454022 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Rough and brittle surface of all the nail plates, although less evident in the fifth fingers. Oil spots and pinpoint leukonychia are visible.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Isotretinoin-induced elkonyxis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Yung" 1 => "P. Johnson" 2 => "M.J. 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Cambiaghi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Dermatology" "fecha" => "1997" "volumen" => "195" "paginaInicial" => "274" "paginaFinal" => "275" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9407179" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Short-term isotretinoin-induced elkonyxis and median nail dystrophy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N. Alli" 1 => "S. Dogan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3109/15569527.2014.902380" "Revista" => array:6 [ "tituloSerie" => "Cutan Ocul Toxicol" "fecha" => "2016" "volumen" => "35" "paginaInicial" => "85" "paginaFinal" => "86" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25799213" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010800000002/v1_201702250104/S1578219016303559/v1_201702250104/en/main.assets" "Apartado" => array:4 [ "identificador" => "6157" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case and Research Letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010800000002/v1_201702250104/S1578219016303559/v1_201702250104/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016303559?idApp=UINPBA000044" ]
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| 2024 Enero | 232 | 45 | 277 |
| 2023 Diciembre | 176 | 31 | 207 |
| 2023 Noviembre | 188 | 33 | 221 |
| 2023 Octubre | 172 | 31 | 203 |
| 2023 Septiembre | 175 | 35 | 210 |
| 2023 Agosto | 105 | 20 | 125 |
| 2023 Julio | 106 | 55 | 161 |
| 2023 Junio | 119 | 31 | 150 |
| 2023 Mayo | 147 | 30 | 177 |
| 2023 Abril | 152 | 29 | 181 |
| 2023 Marzo | 123 | 35 | 158 |
| 2023 Febrero | 155 | 31 | 186 |
| 2023 Enero | 119 | 25 | 144 |
| 2022 Diciembre | 106 | 34 | 140 |
| 2022 Noviembre | 74 | 40 | 114 |
| 2022 Octubre | 72 | 33 | 105 |
| 2022 Septiembre | 67 | 38 | 105 |
| 2022 Agosto | 53 | 39 | 92 |
| 2022 Julio | 50 | 32 | 82 |
| 2022 Junio | 39 | 27 | 66 |
| 2022 Mayo | 131 | 37 | 168 |
| 2022 Abril | 187 | 41 | 228 |
| 2022 Marzo | 175 | 44 | 219 |
| 2022 Febrero | 157 | 37 | 194 |
| 2022 Enero | 134 | 53 | 187 |
| 2021 Diciembre | 113 | 47 | 160 |
| 2021 Noviembre | 95 | 48 | 143 |
| 2021 Octubre | 117 | 62 | 179 |
| 2021 Septiembre | 130 | 44 | 174 |
| 2021 Agosto | 108 | 38 | 146 |
| 2021 Julio | 142 | 37 | 179 |
| 2021 Junio | 165 | 47 | 212 |
| 2021 Mayo | 143 | 50 | 193 |
| 2021 Abril | 312 | 88 | 400 |
| 2021 Marzo | 140 | 47 | 187 |
| 2021 Febrero | 94 | 26 | 120 |
| 2021 Enero | 66 | 24 | 90 |
| 2020 Diciembre | 71 | 26 | 97 |
| 2020 Noviembre | 62 | 12 | 74 |
| 2020 Octubre | 62 | 14 | 76 |
| 2020 Septiembre | 77 | 34 | 111 |
| 2020 Agosto | 65 | 28 | 93 |
| 2020 Julio | 74 | 30 | 104 |
| 2020 Junio | 58 | 34 | 92 |
| 2020 Mayo | 41 | 14 | 55 |
| 2020 Abril | 26 | 19 | 45 |
| 2020 Marzo | 25 | 7 | 32 |
| 2020 Febrero | 2 | 0 | 2 |
| 2020 Enero | 3 | 0 | 3 |
| 2019 Diciembre | 4 | 0 | 4 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 5 | 0 | 5 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 7 | 0 | 7 |
| 2019 Mayo | 4 | 2 | 6 |
| 2019 Abril | 3 | 5 | 8 |
| 2019 Febrero | 1 | 0 | 1 |
| 2018 Diciembre | 5 | 0 | 5 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 3 | 0 | 3 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Febrero | 25 | 3 | 28 |
| 2018 Enero | 59 | 4 | 63 |
| 2017 Diciembre | 39 | 16 | 55 |
| 2017 Noviembre | 33 | 43 | 76 |
| 2017 Octubre | 20 | 37 | 57 |
| 2017 Septiembre | 19 | 31 | 50 |
| 2017 Agosto | 23 | 31 | 54 |
| 2017 Julio | 21 | 15 | 36 |
| 2017 Junio | 32 | 4 | 36 |
| 2017 Mayo | 41 | 13 | 54 |
| 2017 Abril | 37 | 15 | 52 |
| 2017 Marzo | 67 | 37 | 104 |
| 2017 Febrero | 22 | 11 | 33 |
| 2017 Enero | 2 | 7 | 9 |
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