Nail Changes in Patients with Hair Loss

Nail Lichen Planus

We will finish this week with a closer look at the importance of examining the nails in patients with hair loss. 

I generally ask about nail changes in most new patients I see in my office. I often describe hair and nails as "cousins" and it should therefore come as no surprise that many conditions that affect the hair also affect the nails. Patients with alopecia areata, lichen planopilaris, telogen effluvium, drug related hair loss, psoriasis may have changes in their nails.

Some patients with scalp lichen planopilaris have nail lichen planus (LP). The clinical features of nail LP depend on where in the nail the disease is attacking (i.e. whether the matrix or nail plate are involved). Longitudinal ridging and splitting are the most commons clinical signs of nail matrix LP. This is shown in the photo. The splitting often extends right to the end as shown in the picture. However, a wide range of additional nail findings are also possible.

Some forms of nail lichen planus lead to rapid scarring and loss of the nail - (very similar to what is seen in the scalp). Other forms only lead to minor changes that may be difficult to differentiate from age related changes. Some patients have resolution of nail disease even without treatment.

There are a variety of treatments are possible including topical steroids (with occlusion), steroid injections (0.5 to 0.1 mg/nail), intramuscular steroids every 30 days (0.5 mg/kg) and oral steroids for 3 weeks. Antimalarials (i.e. oral hydroxychloroquine), oral retinoids, psoralen, tacrolimus are also used. About 1/2 of patients will not improve despite any type of treatment.