Malnutrition causes zinc deficiency, which might affect the nails. I think you should include this in your differential diagnosis. But then one would expect all nails to be affected?

Thank you Mieke. You are absolutely right. The patient has two fingers affected in the rt hand, and three affected in the lt hand. Both thumbs are the most severely affected as you see in the picture.

yes, zinc deficiency could be responsible for these nails, but usually also would affect mouth . I would not rule out psoriasis. I may be wrong but I saw some pittings in the picture

There is proximal pitting and  a hypertophy of the proximal nail bed on the tumb. It is only the first 3 fingers. Do you see any thickening of skin of fingers over the joints? 

What is the profession of your patient? This could also affect the nails..

It was not the first 3 - it was I and II & IV.

What is obvious is a hyperkeratotic eponychium. One may see this in people exposed to wet work.

I would rule out the fungal issue and the psychological with one exception- if she is bulimic.

Here are some suggestions -

parakeratosis pustulosa

psoriasis

wet-work-reated nail pathology

if not bulimia

Thank you Bimbi. You mentioned psoriasis. The patient has normal skin. Could the patient has psoriasis affecting the nails only? What about lichen planus.

Thank you Uwe. To answer your questions, the patient is a university student, she is not bulimic, although she is underweight, no wet work, and no skin thickening of the finger joints, but she has thin hair.

How can we confirm diagnosis of either parakeratosis pustulosa or psoriasis?

Fungal infecions could compromisse one or two nails, but are improbable in nail hands (they are more probable in toenails). The lesions are clearly onychomadesis (compromising of the proximal edge of the nail) and the causes are autoimmune disease, other major medical illness, neonatal illness, medication induced (antibiotics!), and idiopathic. Other causes: hand-­‐foot-­‐mouth disease, pemphigus vulgaris, critical illness, and antiepileptic and chemotherapeutic agents. If I could opine, attention to trauma (not always described for the patient), once the nails are the most probable nails to be bited for the patient.

Simple remedy for fungal attack, If its fungal attack, apply Neem oil or Paste for 3 days . it will reduce automatically. Being she is the age 20, we have to advice some stress relieving counselling and Yoga therapies.

Thank you Vidal. You mentioned a number of causes for onychomadesis. All of these causes are most probably not present. The patient is not on any medications an she is not known to have any medical problems. You mentioned autoimmune disease. Is there any particular illnes? BTW, ESR here is normal.

Thank you Merish. Your advice is appreciated, but I am not sure that this is a fungal infection.

books.google.co.in/books?isbn=1118286693. This case has to have a detailed history.

Points to be noted  would be . 1 frequent picking of nails, anxiety, family history o Collagen diseases, drug history,

Rule out whether the case is of dystrophy or deformity.

diagnosis is basically by elimination.

1 fungal infection, possibilities. supported by history of trauma, picking, water loving individuls, swimming, anxiety.

Lichen planus, pterygium,

matrix disoders,

may be a work up will help

I would focus on a history from the patient looking for any work and home associated changes resulting in exposure (working with landscaping timbers [arsenic treated], solvent, paints, certain fabric dyes etc.) over the last 6 - 12 months.  If the changes you present in your photograph are restricted to that one hand what has she been doing differently (local toxic exposure).  If the photographs are representative of nails on fingers and toes you may wish to consider systemic exposure to a toxic substance.  Although not all nails are affected, there It is strongly associated with arsenic poisoning, thallium poisoning and to a lesser extent other heavy metal poisoning on nail growth and the pattern is quite similar to that of your patient.

In my opinion it can be due to "physical" stress related to underweight.In the general condition of the patient there must be an abnormal nail matrix function:

nail matrix biopsy will also help. first do a scrappings observe under microscope after KOH mount. Fungal elements will help clinch the diagnosis.

proximal nail disorders are basically to be  considered as a defect in cuticle thereby causing a window for infection to set in. topical cyclopirox available as nail on lacquer may be tried

Many thanks to all colleagues who responded. Perhaps the most relevant points that you mentioned is mal-nourishment and the subsequent abnormal nail matrix function. Is there a particular nutritional supplement that can be used to correct this situation?

Also,Satyaprasad mentioned the use of topical cyclopirox. Is this an antifungal?

take nail scrapping and look under microscope for fungal cause, it is very simple and cost effective, if fungal elements are not found on microscopy then go for culture and if culture is negative then think of some metabolic disorders, consider number of nails affected ... I hope this will help  

The medical precedents are essential for the diagnosis, underweight is one of the principal causes of hair and nail disorders, and in this case it looks as a Beau' s line. Of course previously you must take a direct and culture fungal studies. 

Iam a pediatric Surgeon, so the answer is giving better from dermatologist.

Yes it is antifungal

Nail matrix injury. (Beau's line or onychomadesis) Some nails are spared so a systemic cause is unlikely.  I can spot signs of  chronic paronychia or at least loss of nail cuticle. Look for peri-ungual eczema, habitual and occupational irritant exposures ( water, cleansers, etc), trauma from picking of nail cuticle or manicure, and chronic paronychia. 

I am not sure if my previous answers have reached you.

I would recommend to look for occupational threads (wet work etc.) and habitual factors (picking, eating disorders like bulimia etc.). A nail matrix biopsy could rule out parakeratotic nail diseases.For me it does not look of any infectious etiology. But is is easy to take some nail material for microsopy and fungal culture.

Have you thought of hypoglycaemia? Seen this in a number of hypoglycaemic patients.

My special thanks and appreciation for all colleagues who gave answers, Dilip, Larissa, Ibrahim, Nessa and Atena.  In reference to the contribution of Uwe, thank you for the many helpful answers. You explained some factors that may play a role, however, none of them is relevant in this case. I will go for fungal culture probably in a week time. 

Thank you Maria. Why is hypoglycemia relevant? Should We do Fasting blood sugar or Hb1Ac?

Good approach doc. nail matrix biopsy with fungal cultures.

I agree with Dr.Satya.. ? Fungal infection.

Dear all Yes I think is fungal infection that should be treated with oral antimicotic for six months and in parallel take daily dosis of biotin.

regards,

Would be beneficial to takea more detailed history as fungal nail infection ismore common in the elderly and likely  other risk factors includes immunodeficiency ,psoriasis, swimming etc. 

It seems o me a proximal subungueal onychomycosis  (particularly present during immunodepression…..)

I think it's more possible a fungal infection. Stress injuries are usually longitudinal .

The first picture looks like pitting nail, could it be psoriatic nail?

Deat Najla to diagnose nail dystrophy you should fulfil all diagnostic criteria for nail disease diagnosis:

Nail fold

Nail plate

Nail cuticle

Nail lanula

As well as distribution of disease and pattern

Evolution and duration of the condition

I would like to know if calcium levels have been tested for this patient. Calcium deficiency could lead to such changes. Chronic Iron deficiency could cause koilonychia or spoon shaped nails. So, a combination of calcium, iron , Vitamin C and Vitamin D may be tried. Since these nutrients do not have any side effects, they may be tried for a month to see for any improvement in the condition. Even if it happens to be fungal infection, calcium would still benefit.

Dear Dr Najla differential diagnosis

Nail eczema

Psoriatic nail

Nail lichen planus

Many thanks to all colleagues participating with their knowledge and experience. At follow-up, all nails affected seem to be improving with disappearance of pitting. I will upload new photos once they are ready.

What treatment was the patient given.

 What's your measurements for cure?

In my opinion it can be due to fungal infection be sure by microscope

Perhaps it is soon to decide that there is improvement. The patient was referred to an expert clinical microbiologist for fungal culture. He was adamant that this was not a fungal infection. The goal of treatment now is to foster the patient's body levels of vit D and Ca, by improving diet, increasing sun exposure, and taking vit D and Ca supplements. 

but before that it would be better to estimate vit d levels

fungal infection  . . very well get response with anti fungal drugs.

Peace everyone,

These are the patient's photos after about six months of the appearance of lesions. There is noticeable improvement. Patient was on and off vitamin supplements but never took an antifungal.