Case Study: Chronic Hand Dermatitis with Severe Nail Dystrophy
Case at a Glance
A 40-year-old male with a long-standing history of seasonal eczema presented with a two-year history of worsening, now perennial, hand dermatitis accompanied by significant nail dystrophy, unresponsive to intermittent corticosteroid therapy.
Patient's Story
The patient, a 40-year-old male, reported a lifelong history of eczema on his hands, which was previously confined to the winter months. He lives in a region with relatively mild winters. Over the past two years, the condition has become persistent year-round. More recently, he developed distressing changes to his fingernails, which now grow in cracked, split, and with significant surface waviness. He also noted a near-complete loss of his cuticles. The patient consumes alcohol heavily but is a non-smoker and does not use illicit drugs. He takes probiotics and various other supplements but is on no prescribed medications. Frustrated with the lack of progress and the cosmetic appearance of his nails, he sought a more definitive solution.
Initial Assessment
On presentation, the patient was a well-built male (Height: 6'2", Weight: 240 lbs). Physical examination of the hands revealed moderate erythema and scaling on the dorsal aspects of the fingers. The skin of the proximal nail folds appeared inflamed and puffy, consistent with chronic paronychia. There was a notable absence of cuticles on all fingernails. The nail plates themselves exhibited significant dystrophy, including transverse grooves (Beau's lines), longitudinal splitting (onychorrhexis), and general surface irregularity. The patient had previously consulted two different dermatologists, both of whom diagnosed him with eczema.
The Diagnostic Journey
The patient's history was classic for chronic eczematous dermatitis. His previous treatments included topical steroid creams and at least one steroid injection. While these therapies provided temporary improvement in the skin inflammation, they had no discernible effect on the progressive nail dystrophy. The patient expressed a strong desire to avoid long-term daily steroid use and was motivated to understand the underlying cause. The primary diagnostic challenge was not identifying the eczema itself, but in correctly attributing the severe nail changes to the chronic inflammation of the proximal nail fold (chronic paronychia), which was damaging the nail matrix where the nail plate is formed.
Final Diagnosis
Chronic Hand Dermatitis with secondary Nail Dystrophy and Chronic Paronychia.
Treatment Plan
Given the failure of intermittent corticosteroids to resolve the nail issues and the patient's desire for a steroid-sparing regimen, a new therapeutic approach was recommended. The plan focused on long-term management of the inflammation in the nail follicles and proximal nail folds. The recommendation was to initiate a daily application of a non-steroidal topical agent, such as a calcineurin inhibitor (e.g., tacrolimus or pimecrolimus) or a phosphodiesterase-4 (PDE4) inhibitor (e.g., crisaborole), directly to the affected nail folds. The patient was counseled that this approach targets the root cause of the nail dystrophy and that visible improvement would be gradual, requiring a consistent treatment course of at least 3 to 6 months for new, healthier nail to grow out.
Outcome and Follow-up
The patient was receptive to the proposed treatment plan, as it aligned with his goal of finding a long-term, non-steroidal solution. A follow-up appointment was recommended in 3 months to assess treatment tolerance and initial response of the nail fold inflammation. A subsequent evaluation at 6 months would be necessary to observe significant improvement in the new nail growth. The importance of strict adherence to the daily application regimen was heavily emphasized to achieve the desired outcome.