Nail changes in alopecia areata: an update and review
, and Shari R. Lipner,
Department of Dermatology, Weill Cornell
Medicine, New York, NY, USA
Shari R. Lipner
1305 York Avenue, NY, NY 10021
Conﬂict of interest: Khatiya Chelidze and
Dr. Shari R. Lipner have no conﬂicts of
interest to disclose.
Nail changes are a common feature of alopecia areata (AA) and are a signiﬁcant source of
cosmetic disﬁgurement and functional impairment. This review provides an update of the
prevalence, clinical and histopathological features, pathogenesis, differential diagnosis,
clinical course, prognosis, and management of nail changes in patients with AA. Searches
for peer-reviewed journal articles were conducted using the PubMed/MEDLINE database
with the search terms “nail changes alopecia areata,” “alopecia areata nails,” and speciﬁc
searches on “trachyonychia alopecia areata” and “pitting alopecia areata.” Other sources of
articles included the reference lists of retrieved articles. Nail changes are a common
feature of AA, with an average prevalence of 30%, and can cause signiﬁcant disﬁgurement
and loss of function. Pitting and trachyonychia were by far the most common
manifestations of AA, with an average prevalence of 20 and 8%, respectively. Red spotted
lunulae, onycholysis, and punctate leukonychia were other reported ﬁndings. Other
etiologies, such as onychomycosis or lichen planus, may coexist with or confound the
diagnosis. There is limited published data on the clinical manifestations of AA-associated
nail changes and therapeutic options. Larger controlled trials are necessary to guide
Alopecia areata (AA) is the most common cause of inﬂamma-
tion-mediated hair loss affecting approximately 0.1–0.2% of the
general population, with a lifetime risk of 2%.
Nail changes are
a common manifestation of alopecia areata, and the most fre-
quent features are pitting and trachyonychia.
overlooked on physical examination, nail changes may be pain-
ful or cause problems with activities of daily living. Cosmetic dis-
ﬁgurement may be profound and have a signiﬁcant impact on
quality of life. The pathogenesis of nail changes in this setting is
There is a paucity of evidence-based literature or guidelines
regarding the clinical features and diagnosis of AA-associated
nail changes. The treatment of nail changes associated with AA
is currently guided by clinician experience and evidence from
case series and case reports.
This review aims to summarize the current evidence guiding
the diagnosis and clinical features, prevalence, clinical and
histopathological features, pathogenesis, differential diagnosis,
clinical course, prognosis, and management of AA-associated
Searches for peer-reviewed journal articles were conducted
using the PubMed/MEDLINE database with the search terms
“nail changes alopecia areata,” “alopecia areata nails,” and
speciﬁc searches on “trachyonychia alopecia areata,” “pitting
alopecia areata.” The literature included all articles published
before April 2017. Animal studies were excluded. Studies were
not excluded based on date of publication. Translation was
sought where available for manuscripts not written in English. A
second source of studies came from published articles that
were reviewed for relevant references that had been missed in
online searches. Additionally, when an important article was
identiﬁed, the use of citation indexes was employed to identify
new work by that author or research group.
Nail changes are a common feature of AA. AA-associated nail
changes are often asymptomatic. On physical examination, they
may be subtle and are often overlooked. Thus, the prevalence
of nail changes in patients with AA is likely underestimated.
The reported prevalence of nail changes ranges from 7% to
66%, with an average prevalence of approximately 30%.
(Table 1) Nail changes are more common in patients with more
severe alopecia, such as alopecia areata universalis (AAU) and
alopecia areata totalis (AAT).
Nail changes are also more
common in children than adults with AA.
Children are more
likely to suffer from severe variants of AA, perhaps explaining
the increased frequency of nail changes in this population.
The average age at which nail changes are observed in children
International Journal of Dermatology 2018, 57, 776–783 ª 2018 The International Society of Dermatology