#dermpathJC January 2021 summary

#dermpathJC January 2021:

Thursday, January 28th, 9pm EST

Article discussed: Histopathologic evaluation of nail lichen planus: A cross-sectional study

Authors: Geetali Kharghoria, MD, DNB, Chandra Grover MD, DNB, MNAMS, Sambit Nath Bhattacharya, MD, Sonal Sharma, MD


Editorial: The “frayed nail plate” and further detailed analysis of the histopathologic features of nail unit lichen planus from Dr Adam I. Rubin, MD

Temporary free access courtesy of the Journal of Cutaneous Pathology:



Summary prepared by:  Parneet Dhaliwal, DO (@FollowPath)

Journal Club Summary:


  • Nail involvement can be seen in up to 10% of patients with lichen planus (LP)
  • Fingernails are affected more often than toenails
  • Any part of the nail can be involved, but the nail matrix is characteristic of nail lichen planus (90% of cases) and can present as “longitudinal striations, thinning of nail plate, dorsal pterygium, or trachyonychia.”
  • The disease course progresses slowly but surely, and many patients develop scarring, anonychia, and pterygium formation.
  • Zaias first described histopathology of nail LP in 1970:
    • Hyperkeratosis
    • Hypergranulosis
    • Papillary dermis with band-like lymphocytic infiltrate
    • Basal layer degeneration
    • Colloid bodies
    • Pigment incontinence (melanophages)
  • Major and minor criteria of nail LP:


  • 45 patients from Department of Dermatology and Venereology and Pathology at a teaching hospital in Dehli, India were recruited, consented, and screened
  • Nail biopsy of most representative site was preformed (nail bed vs nail matrix)
  • Major and minor criteria were applied to the biopsies


  • Patient population
    • N=45
    • Mean age: 36.91 +/- 18.27 years
    • M>F (male predominance 64%)
    • Mean disease duration: 29.07 +/ 25.85 months
  • Clinical LP presentations:
    • Oral mucosa LP – 51%
    • Genital involvement – 0%
    • Isolated nail LP – 29%
    • Generalized LP – 28.8%
    • Linear LP – 6.6%
    • Lichen planopilaris (cicatricial alopecia) involving the scalp – 6.6%
    • Palmoplantar LP – 2.2%
    • LP pigmentosus – 2.2%
  • Most common presenting symptom: brittleness or fragility – 40%
  • Nails involved: 8.13 +/ 4.94; Fingernails > Toenails
  • Most common nail plate changes: onychorrhexis (100%), longitudinal melanonychia (88.9%), onychoschizia (82.2%), thinning and distal splitting (62.2% and 48.9%)
  • Most common nail fold changes: ragged cuticle (91.1%), absent cuticle (11.1%), nail fold hyperpigmentation (11.1%)
  • Most common nail bed changes: erythema (88.9%), onycholysis (55.5%), subungual hyperkeratosis (46.7%)
  • Histopath:
    • Major criteria – 51.1%
      • Sawtooth acanthosis – 44.4%
      • Lymphocytic infiltrate – lichenoid band under the dermo-epidermal junction – 24.2%
    • Minor criteria
      • Most common: presence of granular layer in nail matrix and bed epithelium – 51.1%
      • Increased eosinophilia of nail bed keratinocytes – was not seen in any
    • Additional significant finding: “frayed nail plate” due to separation of individual orthokeratotic onychocytes from the nail plate – seen in 33.3% of cases – not previously reported in other studies (see image below)

Most memorable tweets and few pearls from the article’s discussion:

  • Mean age of nail involvement with LP was lower than previously stated – possibly related to increased awareness of cosmetic appearance of nails
  • Mucosal LP was the most common association with nail LP – Dr Rubin also accounts for this association in his nail clinic as well
  • Most common nail fold involvement: ragged cuticle – 95.5%

And now a SPECIAL TREAT for all of you, a SPECIAL interview with Dr Adam I. Rubin (@adamirubin) on the ASDP YouTube channel: Dr Jisun Cha and Dr Gottesman’s #DermpathJC Q&A session with Dr Adam Rubin about lichen planus of the nail unit. While much of the video focuses on the histopathologic features of nail lichen planus and its mimics, the last 15minutes of the discussion are focused on various treatment options for this disease.

Until next month #dermpathJC, stay safe!

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