Nail disorders comprise approximately 10% of all dermatological conditions. Nail changes can be presenting features before other signs of a systemic disease become clinically evident. Therefore, no dermatological evaluation is complete without a thorough nail examination.[1] In children nail diseases are a rather an uncommon cause of dermatological consultation. They may be present at birth or can be acquired. Nail signs of congenital and hereditary nail diseases usually develop early during childhood, and their presence may be a clue to the diagnosis of a syndrome or a systemic disorder. Although the acquired nail conditions observed in childhood are similar to those of adults, their prevalence may vary in the different age groups. For instance, there are some conditions, such as parakeratosis pustulosa and twenty - nail dystrophy (TND), which are exclusively or typically seen in children. Other disorders, such as onychomycosis, are encountered only exceptionally in the first 10 years of life. The common disorders and traumatic nail abnormalities account for 90 – 95% of all nail abnormalities in children. [2]

Various studies conducted earlier had different viewpoints. In a study conducted in 2018 by Atiye akbayrak et al, around 600 patients under age of 18 attending the dermatology OPD showed that the most common nail abnormalities were – Leuconychia, onychoschezzia, onychophagia or onychotillomania in the same order.[3]

Another study published by Iglesias et al, among first 20 patients with nail alterations seen each year during a 5-year period from 1992-1996 shows that the most frequent diagnoses were onychomycosis, nail alterations in genodermatosis, nail alterations associated with other dermatoses, onychocryptosis, and paronychia.[4]

Similarly in a study published by Ayse Akbas et al included 3000 children from age 0-16 attending dermatology OPD clinic of Ankara Paediatric Hospital during January-December 2011, 133 patients had findings and 17 different dermatological conditions were identified. The most common being onychomadesis, paronychia, onycholysis, onychomycosis and systemic nail presentation of systemic dermatosis. [5] A hospital-based original study was conducted at KIMS, Hubballi during Jan 2021 to Jan 2023 by Mendagudli et al. Of the 272 patients included clubbing was the most common nail change encountered, followed by longitudinal ridging and pallor of the nail subsequently. Respiratory system involvement was found as the common cause of clubbing followed by Cardiovascular, liver and Gastrointestinal system involvement. [6]

In a study conducted by Ujjwal Kumar et al in R.D Gardi medical college, Madhya Pradesh, India, 269 cases with various nail changes were enrolled. The most common abnormality observed was onychomycosis followed by nail changes in psoriasis, Lichen planus, Eczema, trachonychia, paronychia, Lichen striatus and Darier’s disease. [7] The present study is being conducted to identify the nail disorders that are most commonly observed in childhood and then review the nail findings that, although uncommon, are of diagnostic significance.

Study setting: Department of Dermatology, Venereology and Leprosy at MVJ Medical College and Research Hospital, Hoskote, Bangalore.

Study population:

The study population consisted of all children 0 to 18years of age attending the Department of Dermatology, Venereology and Leprosy at MVJ Medical College and Research Hospital, Hoskote, Bangalore.

Study design: Observational, Cross sectional study design

Study duration: 6 months

Sampling: All children 0-18years of age attending the Department of Dermatology, Venereology and Leprosy at MVJ Medical College and Research Hospital, Hoskote, Bangalore during the study period of 6 months.

• Inclusion criteria: All children less than 18 years of age visiting Dermatology OPD were taken into study after taking prior informed consent from parent or guardian.
• Exclusion criteria: Patients who are not willing to give consent

Data Collection: Data was collected through patient history taking and clinical examination. Comprehensive nail assessment was done and the findings were recorded along with the recording of demographic data, history and examination of other skin lesions present currently, previous history of any diagnosed skin or systemic condition and drug history. Appropriate statistics were used to analyze the data.

Clinical photographs were taken where necessary to document the findings. Special investigations like nail clipping for bacteriological and fungal infection, nail biopsy and skin biopsy were carried out whenever required.

Ethical considerations: Ethical considerations included approval from the institutional ethics committee, written informed consent from all participants or their legal guardians, and maintaining participant confidentiality by de-identifying data and storing it in secure, password-protected databases.

Statistical analysis: Statistical analysis involved descriptive statistics to summarize baseline demographic and clinical characteristics, bivariate analysis to examine associations between nail disorders and various demographic factors. A p-value of <0.05 was considered statistically significant, and all statistical analyses were performed using SPSS (Statistical Package for the Social Sciences) version 26.0.

During the study period of 6 months a total of 771 patients were enrolled in the study. Amongst them, 396 (51.04%) were male and 375 (48.6%) were female. Their mean age was 7.1 ± 4.7 years.

Total of 466 patients (60.4%) were found to have no nail abnormalities. Out of the remaining 305(39.6%) patients with nail abnormalities, majority were leuconychia 146(18.9%), followed by onychorrhexis 92(11.9%), onychoschizia 25 (3.2%), periungual wart 10 (1.3%) and onychophagia 7 (0.9%).

 TABLE – 1 Demographic details of patients with nail abnormality

Table 1 shows the demographic details of patients with nail abnormality. The mean age of the patients with nail abnormalities is 7.1 ± 4.7. The mean duration of disease is 3.0 ± 1.5. Majority of the patients were male 396 (51.4%) followed by female 375 (48.6%).

TABLE – 2 Distribution of Nail abnormalities seen in the study

Table 2 shows the distribution of nail abnormalities seen in the study. Out of total 771 patients reported in the outpatient department 466(60.4%) were normal with no nail abnormalities. 305 patients were having nail abnormalities. Those having nail abnormalities majority were of leuconychia 146(18.9%) followed by onychorrhexis 92(11.9%), onychoschizia 25 (3.2%), periungual wart 10 (1.3%) and onychophagia 7 (0.9%). Rest all the abnormalities were rare.

TABLE – 3 Distribution of Nail abnormalities according to Age Groups

Table 3 shows the distribution of nail abnormalities according to age groups. It was observed that the distribution of leuconychia , onychorrhexis,  periungual wart, onychophagia were more in the age groups 1-15 yrs. Absent lunula was the change noted in newborns. Children with age group between 1month to 1  year had leukonychia , onychomadesis and beau’s lines as the most common nail abnormalities. All the other nail abnormalities are present in specific age group. When the statistical test was applied the results came out to be highly significant which indicate that age group has a significant association with the nail abnormalities.

TABLE – 4 Distribution of Nail abnormalities according to Gender

Table 4 shows the distribution of Nail abnormalities according to gender. It was observed that the distribution of leuconychia, onychorrhexis, periungual wart, onychophagia were more in males then in females. When the statistical test was applied the results came out to be insignificant which indicate that gender has no association with the nail abnormalities.

TABLE –5 Categorical distribution of Nail abnormalities according to etiology

Table 5 shows the categorical distribution of nail abnormalities according to the etiology or the systemic involvement .Most of the nail abnormalities were found to have physiological or nutritional  etiology like leukonychia, onychorrhexis , absent lunula and onychoschizia. Nail pits superficial, nail pits deep, trachyonychia, ragged cuticle and beau’s lines were associated with alopecia areata, psoriasis with psoriatic arthritis, lichen planus, SLE and AML respectively.

Nail diseases are relatively uncommon in children; however, they play a significant role in identifying various systemic conditions, nutritional disorders and psychophysiological phenomenon in this age group. Nail disorders among neonates and infants are also not very uncommon but mostly related to hereditary or physiological disorders. Studies suggest that nail disorders affect approximately 0.05–3% of infants and young children (8). The prevalence of these conditions varies among different populations (9-12). According to Iglesias et al around 11% of individuals under 17 years old experienced nail-related issues (4).

In the present study, total of 771 patients were examined for the nail abnormalities. Total of 305 nail abnormalities were detected. The mean age of the patients with nail disorders is 7.1 ± 4.7years. The mean duration of disease is 3.0 ± 1.5 years. Majority of the patients were male 396 (51.4%) followed by female 375 (48.6%). So the prevalence of nail diseases was noticed to be perceptibly higher in males than females. These findings are similar to those of a previous study by Ogrum et al., which reported a patient age range of 1 to 17 years and a mean age of 9.18 ± 5.12 years (9). Similar observations were also reported by Neerja et al. in their research (10).

 Out of total 771 patients studied, majority of patients had leukonychia i.e 146 (18.9%), onychorrhexis in 92 patients (11.9%), onychoschizia in 25 patients (3.2%) followed by periungual wart, onychomadesis , beau’s lines, nail pits and other rare abnormalities. The results are similar to the study conducted in 2018 by Atiye akbayrak et al. with  600 patients as sample size where most common nail abnormalities found were Leukonychia, onychoschizia, onychophagia or onychotillomania in the same order.[3]

Leukonychia is defined as whitish discoloration of the nail plate which can be a true leukonychia that involves the nail plate or apparent (pseudo) leukonychia, where there is involvement of subungual tissue due to onycholysis or subungual hyperkeratosis or pathology of matrix or nail bed instead of nail plate. (11)  Minor injuries like nail biting, knocks, and bangs can disrupt nail growth, leading to white spots.

Onychorrhexis is characterized by longitudinal splitting and shallow parallel furrows running on the superficial layer of the nail, affecting a small part of the nail surface to at least 70% of the total nail surface. Nutritional Deficiencies especially of biotin, iron, or other vitamins can lead to onychorrhexis in children. In some cases, particularly in newborns and young children, nail splitting and ridges may be a normal variation, especially due to thinner nail plates (12). In Our study the prevalence of onychorrhexis was seen more in age group between 1 to 15 yrs. The increased incidence can be explained due to socioeconomic, environmental factors and nutritional deficiencies in the population.

Onychoschizia, also called lamellar dystrophy, is characterized by horizontal splits in the fingernails. It usually appears on the thumbs and big toes of the paediatric population during the early years of life. In children, nail biting and thumb sucking are aggravating factors, but trauma is the primary cause (11). Its increased incidence in our study again can be related to the ethnic, social, environmental and nutritional factors.

Onychomadesis is the separation of proximal nail plate from the nail bed by a whole thickness sulcus caused by a temporary arrest in the proximal nail matrix proliferation. Its causes reported in literature include local factors like local trauma and acute paronychia, cytotoxic drugs and systemic diseases like Hand Foot Mouth disease. (13)

Nail abnormalities with infectious etiology like viral, fungal and bacterial infections were unusual with periungual warts most commonly detected infection in our study followed by onychomycosis and paronychia. The results were similar to other studies. As it is uncommon to detect infection as the etiology in pediatric age group the results were comparable.

In a study done by Zahoor et al. the most common nail changes were hand eczema (n=41, 23%) followed by nail changes due to nutritional disorders (n=38, 21%), anaemia (n=34, 19%) and habit tic deformity (n=31, 17.2%)(14). In our study the incidence of eczema was negligible. Triangular nail plate, oval nail plate and absent lunula were rare physiological changes noted in the newborns.

Association with systemic disorders and chronic cutaneous disorders like psoriasis vulgaris , alopecia areata, pemphigus vulgaris were also seen with nail findings like nail pits (superficial) , nail pits (deep), ragged cuticle , onychomadesis, trachyonychia and beau’s lines.(Table 5)

The spectrum of nail abnormalities in childhood and adolescence exhibits some differences from adults. Physiological changes, congenital and hereditary nail abnormalities, nutritional causes, bacterial and viral diseases affecting nails are more common in this age group, while fungal infections of the nails are less common than in adults.[2]

There is a need for complete and systematic examination in paediatric age group in regard to nail examination as many nail changes are crucial for confirmation of cutaneous diagnosis.

This study highlights the significance of nail examination in pediatric population. The high prevalence of nutrition related conditions indicate potential deficiencies in the population, minor trauma associated changes talk about personal habits of the population, physiological changes indicate the importance of counselling of parents.. Infective and congenital conditions underscore the need for comprehensive approach. Overall the findings suggest that nails can serve as a window to systemic conditions in an individual level and a health indicator in the population level.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

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