Onychomadesis as a preemptive sign of pemphigus vulgaris exacerbation

A 56-year-old male, physical worker, with pemphigus vulgaris (PV) lasting for 6 months (diagnosed based on guidelines of the Polish Dermatological Society: linear IgG and complement deposits in intercellular spaces of the epidermis found in the biopsy specimen collected from the vesicular area (direct immunofluorescence), pemphigus type antibodies with titre of 1 : 1000 on monkey oesophagus (indirect immunofluorescence), presence of anti-desmoglein 3 antibodies (result: +++) and of anti-desmoglein 1 antibodies (+++) (ELISA method) was admitted to the Teaching Department of Dermatology with another episode of exacerbation of the disease. Before the admission the patient was treated with prednisolone (60 mg, b.w. 60 kg) and azathioprin (150 mg), with achievement of the phase of consolidation of dermatological lesions. Approximately 2 months before the admission the patient observed onychomadesis of fingernails. Clinical examination demonstrated presence of numerous, locally extensive erosions, dried blisters partially covered with scab on the skin on the trunk, face, upper extremities and scalp (figs. 1–3). There were painful erosions present on oral and nasal mucosa. Additionally, onychomadesis was observed on both hands, on fingers I–IV (figs. 4 and 5). Toenails were not affected. The patient negated any additional ailments, and used no other systemic medication. Changes within fingernails preceded by approximately 7 weeks the appearance of new blisters on the oral mucosa and skin.
Pemphigus vulgaris is a rare acantholytic bullous disease of mucosa and skin, caused by pathogenic auto-antibodies against various desmosomal adhesion molecules [1]. Nail-associated lesions are rarely reported in PV. However, in the 2018 report of Indian authors they were observed in 70% of analysed patients [2]. The most commonly observed lesions occurring in course of PV within the nail system are: paronychia, onychorrhexis, distal onycholysis, onychomadesis, transverse grooves on the nail plate (Beau lines) or dot-like defects of nail plates (pitting), pterygium (a skin fold extending from the proximal wall of the nail and dividing nail plate into two parts), excessive subonychial keratosis, discolorations of nail plates, subonychial petechiae, and even onychodystrophy [2, 3]. Fingernails are usually affected. Part of lesions observed in patients (particularly onychomycosis) result from drug-induced immunosuppression [2]. Onychomadesis is a process associated with...


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