Teledermatology, Case, Onychomadesis, Hand-Foot-Mouth Disease



  1. Malakouti, Mona
  2. Rundle, Chandler
  3. Jacob, Sharon E.


ABSTRACT: Teledermatology is a term to describe the provision of dermatologic medical services through telecommunication technology. This is a teledermatology case of splitting of the nails.


Article Content

In the store-and-forward teledermatology modality, there is a transfer of patient medical information electronically (including history and visual data) obtained in one location to a provider who is in another location (Roman & Jacob, 2015). The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.




Chief complaint: presenting for evaluation of damaged nails.


History of present illness

A 28-year-old lady, with a history of sores in her mouth, malaise, and fever 3 weeks ago, presents with nail changes in multiple nails. Her son was also recently diagnosed with hand, foot, and mouth disease. Prior treatment for skin condition: none. Her primary symptom: none. Prior biopsy: none.



Fully satisfactory.



One image (Figure 1) was provided that showed transverse depression of the proximal nail plate resulting in separation from the proximal nail fold in multiple digits. The distal nail plate remained attached to the distal nail bed.

Figure 1 - Click to enlarge in new windowFIGURE 1. Nail plate detachment from the proximal nail fold.


Figure 1


The presented nail findings and history are most consistent with onychomadesis.



Skin Care and Treatment Recommendations

Reassurance-the nail defect is usually self-limited and will resolve with simple observation as the nail plate grows outward and may be trimmed. If the nail defect interferes with daily activities, removal of the old nail plate may be considered.



Type of Visit

Return to primary care for follow-up after 2-3 months.



Nail production originates at the nail matrix (Braswell, Daniel, & Brodell, 2015). Mitotic activity of the nail matrix may be affected by trauma, a systemic disease, or an infection that may result in morphologic changes of the nail plate; these changes are dependent on severity and duration of the insult (Hardin & Haber, 2015; Tan & Teo, 2014) With minor insult, mild transverse thinning of the nail plate known as Beau lines may occur. Severe or prolonged insult (lasting 1-2 weeks) to the nail matrix that causes growth arrest of the nail plate and subsequent detachment is known as onychomadesis, a more severe form of Beau lines. The distal nail plate may be attached firmly to the distal nail bed but will eventually shed. Onychomadesis may occur in one digit after trauma or be polydactylous depending on the underlying cause. Once the underlying cause is identified, treatment is aimed at avoiding the insult (Braswell et al., 2015). Systemic diseases including hand-foot-mouth disease caused by coxsackie or enterovirus have been reported to cause onychomadesis weeks after infection. Reviewing recent viral infections that occurred within 1-2 months of presentation with onychomadesis is helpful (Clark, Silverberg, & Weinberg, 2015). Of special note, pemphigus vulgaris manifests as acute or chronic paronychia and onychomadesis (Serratos & Rashid, 2009). Furthermore, chemotherapy and antiepileptic medications have been known to cause onychomadesis (Hardin & Haber, 2015), as have retinoids (Piraccini, Iorizzo, Starace, & Tosti, 2006).




Braswell M. A., Daniel C. R. III., Brodell R. T. (2015). Beau lines, onychomadesis, and retronychia: A unifying hypothesis. Journal of the American Academy of Dermatology, 73(5), 849-855. [Context Link]


Clark C. M., Silverberg N. B., Weinberg J. M. (2015). What is your diagnosis? Onychomadesis following hand-foot-and-mouth disease. Cutis, 95(6), 312, 319-320. [Context Link]


Hardin J., Haber R. M. (2015). Onychomadesis: Literature review. British Journal of Dermatology, 172(3), 592-596. [Context Link]


Piraccini B. M., Iorizzo M., Starace M., Tosti A. (2006). Drug-induced nail diseases. Dermatologic Clinics, 24(3), 387-391. [Context Link]


Roman M., Jacob S. E. (2015). The need for encryption in mobile teledermatology. Journal of Cutaneous Medicine and Surgery, 19(2), 107. [Context Link]


Serratos B. D., Rashid R. M. (2009). Nail disease in pemphigus vulgaris. Dermatology Online Journal, 15(7), 2. [Context Link]


Tan K. W., Teo R. Y. (2014). Shedding of the fingernails. The diagnosis: Onychomadesis. Cutis, 94(2), E3-E4. [Context Link]


1The standardized teledermatology reader report format is available for authors on the journal's Web site ( and on the submissions website online at [Context Link]