Introduction

Onychomadesis is the spontaneous complete deta chment of the nail from its proximal end, which can affect hands and feet. Although it is not a common finding in children, its presence causes great concern among family members and caregivers¹. Among the probable etiologies of the nail plate detachment are local causes, such as paronychia and trauma, in which one or two nails are usually affected; and systemic cau ses, in which several fingernails and toenails are affec ted². These latter include malnutrition, medication (an tibiotics, retinoids, lithium, anticonvulsants, and cyto- toxics), some infections (candidiasis, syphilis, scarlet fever, hand-foot-and-mouth disease), and other patho logies, such as Kawasaki syndrome, thrombocytopenia, systemic lupus erythematosus, acrodermatitis entero- pathica, epidermolysis bullosa, hypoparathyroidism, and Stevens-Johnson syndrome. There are also familial forms with a dominant inheritance pattern and conge nital forms, possibly related to the delivery stress^2,3.

The association between onychomadesis and hand- foot-and-mouth disease has been described in recent years and was first reported in 2 0 00⁴. Since then, both sporadic and epidemic cases have continued to be re ported as to show this relationship⁵.

The hand-foot-and-mouth disease is a common childhood infection caused by Enteroviruses of the Picornavirus family. It occurs mainly in summer and autumn and is transmitted between people via the fecal-oral route and to a lesser extent by respiratory secretions⁶.

The most frequent etiologic agents reported in the literature are Coxsackievirus A16 (most common) and Enterovirus 71 (most common morbidity and mortali ty), and other serotypes have also been isolated⁷.

Clinically it is characterized by a palmoplantar vesi cular eruption and erosive stomatitis. It usually occurs in children under ten years of age, but may also affect adults, given its high degree of infectivity⁸. In addi tion to the typical clinical presentations in the mouth, hands, and feet, in recent years more generalized and severe cases have been described, where diverse skin lesions in the perioral area, neck, trunk and extremities, and skin detachment in palms and soles has been described. These more severe cases have been reported associated with Coxsackievirus A6⁹.

The objective is to present a characteristic clinical case of hand-foot-and-mouth disease with the consequent nail findings described.

Clinical case

A three-year-old male patient with unremarkable past medical history. The patient is taken by his parents to a health center due to a five-day history of mi crovesicular lesions with an erythematous rim, which initially appear in the perioral area, then extended to the hands, arms, buttocks, thighs, and feet; he is in good general condition, asymptomatic.

The diagnosis of hand-foot-and-mouth disease is made, with more extensive lesions than the usual clinical picture.

General moisturization and control measures are indicated according to evolution.

He evolved with complete resolution of the skin le sions and remission without any residual lesion.

After one month, the complete proximal detach ment of nail plates was observed, which corresponds to the characteristic onychomadesis as a late compli cation of this viral disease (Figure 1). A few days after the initial consultation, the father presents a similar, milder eruptive skin condition, also with subsequent detachment of his nails (Figure 2).

Figure 1 Onychomadesis of the toes in a child. 

Figure 2 Onychomadesis in a child and his parent. 

Father and son have onychomadesis in some fin gernails and toenails, with complete detachment of nail plates, which resolved spontaneously between six to eight weeks, with the growth of healthy new nails.

Discussion

Nail alterations that often occur as a late conse quence of hand-foot-and-mouth disease are Beau’s lines and onychomadesis. Stopping the proliferation of the nail matrix can lead to partial or total damage of the nail plate. Beau’s lines are transverse grooves in the nail that run from one lateral fold to the other, resul ting from the temporary interruption in the formation of the nail plate. Onychomadesis would represent the most severe form of this phenomenon, since the cau sative agent would act for a longer period of time, with the involvement of the entire thickness of the nail pla te and its consequent detachment from the nail bed¹. This is a consequence of the complete and transitory inhibition of nail growth for one or two weeks. The nail continues to grow over the nail bed, remaining attached to the underlying tissues and detaching as it loses its connection with the new nail that is beginning to grow at that momento¹⁰.

The pathogenesis of onychomadesis in hand- mouth disease has not been fully clarified. Besides arresting the function of the nail matrix, it has been proposed that maceration due to digital blisters, inflammation of the proximal nail bed and direct toxic effect of the virus can be involved¹¹.

The diagnosis of onychomadesis is clinical, so it is essential to make an accurate anamnesis aimed at finding the associations previously described. Further examination would only be necessary in cases where the history is unclear or unreliable if a systemic cause or the presence of a local infectious agent is suspected. It is worth mentioning the ultrasonography of the nail as a complementary resource in case of doubt in the diagnosis, providing also chronological data that allow establishing the date of the original injury¹². This type of study is only made in exceptional cases, as it is not always available, is operator-dependent and involves an additional cost that is unnecessary in a typical cli nical situation.

Due to the affected nail plate has already been de tached and the newly growing nail has appeared, no treatment is necessary. In most cases, complete reco very of the nail occurs between six and 12 weeks.

It is only recommended to cleanse the area and to avoid injuries¹.

Conclusion

Due to the frequency of hand-foot-and-mouth di sease cases has been increasing¹⁰, we are likely to face this exanthem and its consequences more frequently. Therefore, we must know how to recognize not only the characteristics of the clinical picture in its acute phase but also later consequences such as onychomadesis.

In cases of children with onychomadesis, a history of the viral disease should be sought in the two months prior to the onset of this phenomenon. In this context, the most frequently reported etiology is hand-foot- and-mouth disease.

Likewise, when the diagnosis of this virus is made, parents and caregivers should be warned of the possibility of onychomadesis from four weeks after the viral infection¹³. This phenomenon occurs most often in fingernails, and may also occur in toenails¹⁴.

Since pediatricians receive the vast majority of ca ses, it is essential to be familiar with this association. This will reassure the family members of the affected child and avoid unnecessary referrals and treatment.

Ethical responsibilities

Human Beings and animals protection: Disclosure the authors state that the procedures were followed according to the Declaration of Helsinki and the World Medical Association regarding human experimentation developed for the medical community.

Data confidentiality: The authors state that they have followed the protocols of their Center and Local regulations on the publication of patient data.

Rights to privacy and informed consent: The authors have obtained the informed consent of the patients and/or subjects referred to in the article. This docu ment is in the possession of the correspondence author.

Financial Disclosure: Authors state that no economic support has been asso ciated with the present study.

Conflicts of Interest: Authors declare no conflict of interest regarding the present study.