Photo Quiz

Nail Changes Following a Viral Infection


Am Fam Physician. 2019 Oct 15;100(8):497-498.

A seven-year-old boy presented with abnormal growth of his fingernails that began two weeks prior. He had no other symptoms, including pain or pruritus on his hands or around his nails. He did not have fevers, chills, nausea, vomiting, or change in activity. He had hand-foot-and-mouth disease two months earlier that was diagnosed based on vesicular lesions in his mouth and on his hands and feet. The lesions completely resolved, and his mother reported that he returned to normal activity.

On physical examination, the patient appeared well and active. The nails on both hands were discolored and looked like they were peeling (Figure 1 and Figure 2). He had no other skin lesions, and the rest of the physical examination was unremarkable.






Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Child abuse.

B. Onycholysis.

C. Onychomadesis.

D. Onychomycosis.

E. Pathologic grooming.


The answer is C: onychomadesis. Onychomadesis is a phenomenon in which the nail plate separates from the nail bed because of cessation of activity in the nail matrix, usually followed by incomplete shedding of the nail.1 Onychomadesis can develop 28 to 56 days after hand-foot-and-mouth disease, which is most often caused by Coxsackie virus infection.2 Changes in the nails are not permanent, and normal nail growth typically occurs within one to four months.2 The characteristic disruption of the nail plate and proximal nail bed gives the nails a peeling appearance.

Nail abnormalities during childhood are generally uncommon.2 Other causes of onychomadesis include trauma or injury, systemic disease, infection, drug use, radiation, and chemotherapy.13 Onychomadesis following hand-foot-and-mouth disease can occur on the nails of the hands or feet, even on digits not affected by the illness. In this patient, the

Address correspondence to Martha McGarey Metzgar, DO, FAAFP, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Hardin J, Haber RM. Onychomadesis: literature review. Br J Dermatol. 2015;172(3):592–596....

2. Apalla Z, Sotiriou E, Pikou O, et al. Onychomadesis after hand-foot-and-mouth disease outbreak in northern Greece: case series and brief review of the literature. Int J Dermatol. 2015;54(9):1039–1044.

3. Salgado F, Handler MZ, Schwartz RA. Shedding light on onychomadesis. Cutis. 2017;99(1):33–36.

4. McDonald KC. Child abuse: approach and management. Am Fam Physician. 2007;75(2):221–228. Accessed July 25, 2019.

5. Zaias N, Escovar SX, Zaiac MN. Finger and toenail onycholysis. J Eur Acad Dermatol Venereol. 2015;29(5):848–853.

6. Westerberg DP, Voyack MJ. Onychomycosis: current trends in diagnosis and treatment. Am Fam Physician. 2013;88(11):762–770. Accessed July 22, 2019.

7. Khumalo NP, Shaboodien G, Hemmings SM, et al. Pathologic grooming (acne excoriee, trichotillomania, and nail biting) in 4 generations of a single family. JAAD Case Rep. 2016;2(1):51–53.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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