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JAMA Clinical Challenge
November 8, 2016

Long-standing Onychodystrophy in a Young Woman

Author Affiliations
  • 1Department of Dermatology, Weill Cornell Medicine, New York, New York
JAMA. 2016;316(18):1915-1916. doi:10.1001/jama.2016.16167

A 34-year-old woman presenting to the clinic reported having thickened toenails for more than 20 years. She had used an over-the-counter antifungal cream intermittently to treat pruritus of her feet. Her father and sister had similar, but less severe, toenail problems. She had no history of dandruff, skin problems, or joint pains. Her medical history was significant for asthma, but she had been symptom free for more than 7 years without medications. She reported no pain in the nails or difficulty ambulating. The patient, a stay-at-home mother, denied prior toenail trauma, frequent sports activities, or hyperhidrosis of the feet. She had undergone no previous diagnostic tests or treatment for her toenails. Physical examination revealed thickening, yellow discoloration, and subungual hyperkeratosis of all 10 toenails (Figure, panel A). Scale was present on the plantar surface skin and in the web spaces (Figure, panel B). Examination of the fingernails, scalp, and skin was normal.