Comparative analysis of the occurrence of Bo lines after sports injuries and COVID-19 (clinical case)

Dear Editor: The effects of chemotherapeutic agents on rapidly proliferating organs, such as skin, hair, and the gastrointestinal tract are well-known, and clinically manifest as exfoliative dermatitis, alopecia, and diarrhea, respectively. As a skin appendage, nails are no exception. For example, cytotoxic chemotherapeutic agents can induce temporary arrest of proliferative function of the nail matrix, which can be clinically observed as Beau's lines in the nail plate1,2. A 49-year-old male with lung cancer was referred for evaluation of nail changes that had developed on both fingernails and toenails after initiation of chemotherapy with paclitaxel-cisplatin at 3-week intervals. Both nail changes developed at the same time. Physical examination revealed multiple white lines on the nail plates, with regular distance between the lines reflecting chemotherapy cycles of 3-week intervals. With regard to the detailed morphology of the white lines, interestingly, both fingernails and toenails displayed multiple transverse bands of white discoloration and depressions, known as Mees' lines and Beau's lines, which alternately developed on the nail plates (Fig. 1). Both were more prominent on the toenail plates (Fig. 2A). The width of stripes was thicker on the fingernail plate than the toenail plate with regular intervals. Upon completion of chemotherapy, white transverse lines migrated distally as the nail grew, and no new stripes developed (Fig. 2B). Along with migration of nail growth, all stripes disappeared. Fig. 1 Both thumbnails showed multiple transverse bands of white discoloration and depressions of the nail plates, which are alternate layers of Mees' lines and Beau's lines. Fig. 2 (A) Both toenails also showed multiple transverse bands, which are alternate layers of Mees' lines and Beau's lines. Both Mees' lines and Beau's lines were more prominent on the toenail plates. (B) After 4 months, he discontinued the chemotherapy and ... Our patient received combination chemotherapy with paclitaxel-cisplatin. Docetaxel is most frequently responsible for nail matrix damage. Together with docetaxel, paclitaxel forms the drug category of the taxanes. But, it rarely causes side-effects affecting nails, therefore related publications are sparse3. The other component of the chemotherapy was cisplatin, one of the family of drugs called platinum compounds. We have not found any report on similar nail alterations caused by cisplatin. We now briefly discuss the relationship between Mees' lines and Beau's lines in this case, and the implication of nail changes with respect to the clinical course of chemotherapy. Cytotoxic chemotherapeutic agents can induce temporary arrest of proliferative function of the nail matrix, which may manifest as multiple Mees' lines or Beau's lines in the nail plate4. Mees' lines are signs of toxicity to the distal nail matrix, resulting in parakeratosis of the nail plate, which becomes white and opaque. Drug-induced true leukonychia (Mees' lines) appears as one or several parallel transverse white bands affecting all nails at the same level and moving distally with nail growth5. Beau's lines are typical signs of acute toxicity to the nail matrix with transient arrest in nail plate production. The nail shows a transverse depression that migrates distally as the nail grows5. Both are signs of toxicity to the nail matrix. What was the difference between fingernails and toenails with leukonychia in this case? We hypothesize that the difference of proliferative potential between fingernails and toenails leads to different clinical manifestations. A fingernail takes approximately 40 days to emerge from the proximal nail fold and a toenail approximately 80 days5; therefore, we suppose that the proliferative potential of a fingernail is higher than that of a toenail. In general, organs of rapid mitotic activity are damaged more severely from chemotherapy in much the same way fingernails are more vulnerable to anticancer drugs than toenails. Interestingly, in our patient, rapidly proliferating fingernails were less affected by chemotherapeutic nail matrix damage; consequently, less severe depression and less opaque Mees' lines manifested. In general, slowly proliferating toenails are seriously affected, and these show definitive Beau's lines and more opaque Mees' lines. The depth of the depression indicates the degree of the damage, and the width indicates the duration of the insult6. Different mechanisms lead to different nail changes. A decrease in matrix cell proliferation can lead to Beau's lines, which are associated with temporary cessation of nail growth according to cycles of chemotherapy at 3-week intervals. As a result of proliferative function turnaround, disorganized keratinization of the nail matrix results in parakeratosis of the nail plate, which becomes white and opaque, known as Mees' lines7. Beau's line or Mees' line can sometimes be one of the first symptoms after chemotherapy; however, to the best of our knowledge, development of Beau's lines in patients with Mees' line has not previously been reported.

We report a case of Beau’s lines at even intervals and onycholysis caused by chemotherapy. The patient with a diffuse large cell B cell lymphoma (DLBCL) stageIIA underwent combination chemotherapy consisting of R-CHOP (Rituximab, cyclophosphamide, doxorubin, vincristine, predonisolone) every three weeks (21-day intervals) six times. As he was treated with R-CHOP, he noticed each Beau’s lines (transverse groove) on all 20 nails each time. In addition, he had onycholysis caused by cyclophosphamide and doxorubicin treatment. Two months after discontinuation of chemotherapy, Beau’s lines disappeared.

Beau's lines are transverse grooves in the nail plate that result from transient interruption of the growth of the proximal nail matrix after severe disease. The aim of this study is to systematically report all evidence on the association of Beau's lines with COVID-19 infection or vaccination against COVID-19. PubMed and Scopus databases were searched up to January 2024 for articles reporting Beau's lines associated with COVID-19 infection or vaccination for COVID-19. CRD42024496830. PubMed search identified 299 records while Scopus search identified 18 records. After screening the bibliography, nine studies including 35 cases were included in our systematic review. The studies were reported from different areas around the world. Included studies documented Beau's lines following COVID-19 vaccination (two studies) or after COVID-19 infection (seven studies). High variability was recorded in onset and resolution times among included cases, averaging 3 months and 6 months after COVID-19 infection, respectively. In the two studies reporting Beau's lines after vaccination, onset was at 7 days and 6 weeks and resolution occurred after 8 and 17 weeks, respectively. To the best of our knowledge, this is the first systematic review reporting the association of Beau's lines with COVID-19 infection and vaccination. Severe immune response can result in the formation of these nail disorders. Of importance, Beau's lines represent a potential indicator of prior severe COVID-19 infection or vaccination for COVID-19, as well as a sign of long COVID-19 syndrome.

Dermatology encompasses the evaluation and management of localized conditions that affect the nail plate, including trauma, primary dermatoses involving the nail bed and nail matrix, and systemic disorders with manifestations that impact the nail unit. In addition to traumatic events that can alter the nail unit, localized conditions such as periungual dermatitis and infections, as well as generalized diseases, can affect the nail matrix, resulting in temporary growth arrest of the nail plate. This can present as a groove (Beau's line) in the nail plate that progressively grows out as the nail continues to grow. Forensic pathology includes forensic anthropology. Disease and starvation are the most common etiologies associated with growth arrest of the long bones near the epiphyseal plate; the radiolucent horizontal bands (Harris lines) are only observable on the roentgenogram. Localized injuries, malnutrition, and childhood illnesses can result in growth arrest of enamel formation in the teeth (linear enamel hypoplasia); this condition appears as white pits, grooves, and/or bands on the crowns of permanent teeth. A 65-year-old man experienced a trauma-associated Beau's line on his left great toenail plate. He developed a subungual hematoma; approximately 10 weeks after the injury, he noted the appearance of a Beau's line. Growth arrest of the nail plate (Beau's lines), growth arrest of the long bones near the epiphyseal plate (Harris lines), and growth arrest of the teeth's enamel formation (linear enamel hypoplasia) can be caused by adverseevents such assystemic illnesses, malnutrition, medication effects, and trauma. In conclusion, diagnostic stigmata of growth arrest, such as Beau's lines of the nail plate, Harris lines of the long bones, and linear enamel hypoplasia of the teeth, can be detected during the cutaneous inspection of the nails, the radiologic evaluation of the long bone, and the oral examination of the teeth.

Beau's lines are transverse grooves in the nail plate that result from transient interruption of the growth of the proximal nail matrix. These rare nail disorders can be triggered mostly by infections or systemic diseases. We describe a 65-year-old man who presented with nail changes on all fingernails. The patient, a non-smoker with no medication history, had severe immune responses during two hospitalisations, 9 and 4 months ago, for COVID-19. Both hospitalisations were accompanied by markedly elevated interleukin-6 levels, and treatment with tocilizumab on top of dexamethasone was required. The present examination revealed Beau's lines which were associated with both prior COVID-19 infections. Although nail changes look harmless, seeking Beau's lines during the physical examination might indicate past severe COVID-19 infection and a higher probability for reinfection and rehospitalisation. Beau's lines are grooves that traverse the nail plate horizontally.The appearance of Beau's lines may indicate past severe COVID-19 infection.Beau's lines can potentially indicate a higher probability of COVID-19 reinfection and rehospitalisation.

We describe a case of moderate hand–foot syndrome and nail toxicity simultaneously occurred in a 69-year-old man with advanced gastric cancer (cT4-N3-M1, G3) previously treated with numerous antineoplastic agents, including PELFw (5-fluorouracil, epidoxorubicin, leucovorin, and cisplatin) and taxoids. Due to a recalcitrant course, the above therapeutic agents were discontinued for 4 weeks and he was given solely capecitabine 1250 mg twice daily for 2 weeks at 3-weekly intervals. After the third course of chemotherapy he developed a moderate hand–foot syndrome, acute paronychia, exudative hyponychial dermatitis, multiple periungual pyogenic granuloma-like lesions, onychomadesis and onycholysis (1, 2). (A,B) Exudative hyponychial dermatitis with transparent nonviscous exudative discharge; hyperkeratosis, onycholysis, onychomadesis and periungual pyogenic granuloma-like lesions (A,B) Subungual hyperkeratosis, onycholysis, and Beau's lines; erythema and desquamation involving the hands Clinical examination revealed subungual hyperkeratosis, onycholysis, onychomadesis, acute paronychia and transparent malodorous, nonviscous, exudative discharge from toenails, especially upon squeezing. Slightly erythematous papular and vascular lesions (granuloma-like) in the proximal nail fold region of four of his toes and Beau's lines were also observed. Hypercurvature on the transverse axis of the nail plates was present, giving a pinched shape to the free edges. No other nail changes such as leukonychia or hyponychium hyperpigmentation were observed. Microbiological examination did not reveal bacterial infections, and repeated potassium hydroxide examinations of the nails did not show fungal hyphae. Treatment was initiated with soaking the nails with 0–5% potassium permanganate solution and application of gentamicin ointment. The hyponychial dermatitis and the above-described nail changes, including periungual pyogenic granuloma-like lesions, gradually resolved after the cessation of capecitabine for 8–12 weeks. The patient lost the nail of the great toes after about 3 weeks. Naranjo algorithm evaluation obtained a score of 9, which indicates a high probability that the adverse reaction was due to the drug [1]. Several chemotherapeutic agents, including taxoids, cyclophosphamide, doxorubicin/daunorubicin, 5-fluorouracil and vincristine, and combinations have been reported to induce nail and periungual changes: alterations may involve nail matrix (e.g. Beau's lines, onychomadesis, hyperpigmentation), nail bed (e.g. onycholysis, subungual haemorrhage, haematoma), and proximal nail fold (e.g. acute paronychia, periungual pyogenic granuloma) [2]. These adverse events are mostly mild to moderate in severity, but, if not properly managed, can result in significant pain and interfere with activities of daily living. Capecitabine (Xeloda®; Roche, Basel, Switzerland) is a fluoropyrimidine carbamate with antineoplastic activity. It is an orally administered systemic prodrug of 5′-deoxy-5-fluorouridine which is converted to 5-fluorouracil and preferentially activated at the tumour site. Fluoropyrimidine carbamate is a chemotherapeutic drug currently approved by the US Food Drug Administration for use as first-line therapy in patients with metastatic colorectal cancer or metastatic breast cancer. Capecitabine has also been used, alone or in different combinations, as a treatment of advanced gastric cancer, with interesting results [3, 4]. In clinical trials, the most frequent side-effects include gastrointestinal and haematological complications, hand–foot syndrome, hyperbilirubinaemia and anorexia. Although hand–foot syndrome is observed in up to 50% of patients treated with capecitabine, other mucocutaneous side-effects such as dermatitis, stomatitis, skin/nail discoloration and alopecia have been rarely reported [3, 4]. The incidence of nail changes is probably underestimated and still ill-defined; in particular, although the effects of taxoids [5] and epidermal growth factor receptor inhibitors (anti-EGFR agents) [6] are well described, there are, to our knowledge, only few reports of nail toxicity associated with capecitabine as monotherapy [7–9]. The aetiology of chemotherapy-induced nail changes is unclear; probably, immunosuppression and consequent colonization of the nail bed, change and disruption of the nail plate, subungual oedema with loss of adhesion between nail bed and nail plate and inflammatory and erosive processes may contribute to the development of nail and periungual abnormalities [7–10]. The nail toxicity seen in our patient was unique for the simultaneous occurrence of subungual hyperkeratosis, onycholysis, onychomadesis, paronychia, hyponychial dermatitis and periungual pyogenic granuloma-like lesions. As capecitabine is being increasingly used in the treatment of advanced breast and colorectal cancers as well as other solid cancers, clinicians should be aware of the novel clinical side-effects of this medication that could lead to substantial subjective toxicity, with impairment of quality of life and discontinuation of chemotherapy.

A 28-year-old female received six cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone chemotherapy to treat diffuse large B-cell lymphoma. She completed her treatment (see Figure 1) 3 weeks before this photograph. Examination showed multiple white lines on the fingernails, known as Mees’ lines. Mees’ lines are transverse, nonblanching white bands that run parallel to the lunula around the entire nail bed. The lines matched the start of each cycle, with the distance between the lines representing the time interval between cycles. In this patient, four lines can be identified with consistent intervals on the body of her nails, while the fifth and sixth lines are seen at a more significant distance at the nail-free edge. This might be related to treatment delay after cycle 2 (40 days) due to intensive care unit admission with sepsis and coronavirus disease (COVID-19) pneumonia. In the third and fourth cycles (the outer lines on the nail bed), we can see roughness and indentation (on the left-hand thumb and index finger), representing Beau's lines. Beau's lines are transverse depressions in the nail plate caused by transient cell division interruption in the proximal nail matrix. Both lines are commonly seen in patients with a history of chemotherapy exposure. The authors declare they have no conflicts of interest. The photograph was taken with the patient's informed consent and in accordance with the declaration of Helsinki The authors received no specific funding for this work. Informed consent was obtained. The authors declare that the data supporting the findings of this report are available within the article.

Dear Editor: Hand-foot-mouth disease (HFMD) is a common illness of children, characterized by fever and vesicular eruptions on the hands, feet, and mouth. Variable strains of viruses are known to be related, such as coxsackievirus A5, A6, A7, A9, A10, A16 (most common), B1, B2, B3, B5; echoviruses E3, E4, E9; and enterovirus 711,2. Onychomadesis is defined as proximal nail plate separation from the nail matrix and nail bed caused by a temporary arrest in nail matrix activity, and may present as a Beau's line. We report on four Korean children who developed onychomadesis about 4 weeks after HFMD. The children presented with transverse Beau's line or onychomadesis on the fingernails or toenails (Fig. 1). They all had HFMD about a month ago, and their information is briefly summarized in Table 1. All patients had no history of trauma and periungual dermatitis, and the affected nails were not of the fingers involved in HFMD. Some were given antibiotic ointment, whereas spontaneous regression was expected in others. The affected nails eventually shed completely without deformity in the new nails. Conditions that can cause onychomadesis include severe systemic diseases, nutritional deficiencies, trauma, periungual dermatitis, chemotherapy, fever, drug ingestion, and infection1. Nail matrix arrest with fever, infection, systemic disease, or drug exposure can be explained by inflammation in the periungual and matrix regions, inhibition of cellular proliferation, alteration in the quality of manufactured nail plate, and nerve injury or dysfunction2. The mechanism of onychomadesis after HFMD is not fully understood. However, viral infection is responsible for onychomadesis, as a temporal latency exists between HFMD and onychomadesis. Bettoli et al.3 reported that inflammation secondary to viral infection around the nail matrix may be induced directly by viruses or indirectly by virus-specific immunocomplexes and consequent distal embolism, and Cabrerizo et al.4 suggested that virus replication directly damage the nail matrix, based on the presence of coxsackievirus 6 in shed nails. Because fingernails with onychomadesis are not always of the fingers affected by HFMD, as in our cases, an indirect effect of viral infection on the nail matrix is more plausible. Onychomadesis can also occur on toenails; however, it is less frequent even when vesicles were present on the feet previously. Whether this is due to less frequent detection or a different mechanism is not known. As previously mentioned, many different types of viruses are known to be associated. Furthermore, more than one viral strain may be involved in nail matrix arrest1. In reality, onychomadesis cases after HFMD are underestimated because onychomadesis spontaneously regresses, and the interval between HFMD and onychomadesis is about a month. In all cases, the onset of onychomadesis was about a month or two later than the peak prevalence of HFMD (May-August 2013)5. By reporting these cases for the first time in Korea, we emphasize the importance of recognizing the association between HFMD and onychomadesis especially when children with onychomadesis present a month after an HFMD outbreak, to avoid unnecessary overtreatment and to reassure the patient's parents. Fig. 1 (A) Three-year-old boy with onychomadesis on the left middle, right index, and right ring fingernails. (B) Four-year-old girl with prominent Beau's lines on the left index and middle fingernails. (C) Third patient with onychomadesis on the left index ... Table 1 Characteristics of cases of onychomadesis after hand-foot-mouth disease

Objective: Beau lines, onychorrhexis, and psoriatic lesions of the dorsal nail plate may be missed by photographic methods, indicating a need for surface texture measurement methods that are more quantitative, sensitive, and repeatable than visual inspection or imaging. We conducted this study to evaluate the utility of surface texture measurements of cadaveric nails that can be associated with histopathological studies in the future. Methods: The nail plates of 4 cadaveric right pollices and halluces were cleaned and molded, cast in clear epoxy, and scanned with a Sensofar S Neox optical profilometer. A one-way analysis of variance was performed to determine statistical significance of findings. Results: Almost no differences were observed between the pollex and hallux scans and between the distal and proximal regions. The greatest differences were found between individuals. Although lower magnification (5×) is less sensitive than higher magnification (20×), the lower magnification represented and characterized more of the dorsal nail plate. Conclusion: The dorsal nail plate areal roughness has a measurable range of values that may serve as a starting point for evaluating pathological findings, particularly Beau lines and psoriatic lesions. The sensitivity of these techniques may be especially valuable in the recognition of less severe states of these diseases that may enable the diagnosis of earlier stages of growth disruptions (Beau lines) or psoriasis. Such applications could be especially useful in investigations of the health of wildlife populations or vulnerable human populations with incomplete treatment records.

A 3-year-old girl was admitted to our hospital with suspected acute onychodystrophy. Her mother mentioned that she had recently been treated for scarlet fever, which occurred eight weeks prior. The girl had experienced symptoms such as sore throat, pain while swallowing, “strawberry tongue,” and a “sandpaper” rash on her trunk, but no fever or presence of vesicles or pustules. The parents noticed the changes in the girl's nails before seeking medical attention. During the physical examination, Beau's lines were observed on all her fingernails (Fig. 1). Onychomadesis, ranging from mild transverse nail plate ridges (Beau's lines) to complete nail shedding, can be associated with various conditions such as hand-foot-mouth disease, measles, Stevens-Johnson syndrome, Kawasaki disease, and post-chemotherapy.1Chu D.H. Rubin A.I. Diagnosis and management of nail disorders in children.Pediatr Clin North Am. 2014; 61: 293-308Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Therefore, a detailed medical history is crucial in establishing a differential diagnosis. Although there have been rare mentions of scarlet fever as a cause, the mechanism of nail matrix arrest following infection remains unclear. In general, no treatment is necessary, as spontaneous resolution occurs within 1–2 months. The authors have no conflicts of interest relevant to this article. This work was supported by the Hangzhou Science and Technology Bureau, China (grant no. 202004A17).

A 62-year-old woman received six cycles of docetaxel chemotherapy during a six-month period for recurrent metastatic breast cancer. She had completed treatment four weeks before this photograph was taken. Six evenly spaced, transverse lines were noted on all her fingernails. Beau's lines are transverse depressions in the nail plate caused by temporary cessation of cell division in the proximal nail matrix. The condition may be caused by local disease of the nail fold or a systemic insult, such as an illness or the administration of a drug.

<h3>To the Editor.—</h3> Beau's lines are transverse grooves on the nail plate that develop as a consequence of any acute illness or stressful condition. First described by Beau in 1846,¹they occur as a result of myocardial infarction, measles, mumps, pneumonia, or pulmonary embolism.²A case is described where multiple Beau's lines were observed in a patient in whom the lines could be attributed to recurrent attacks of erythema nodosum leprosum, or a type 2 lepra reaction. <h3>Report of a Case.—</h3> A 36-year-old man, who had been diagnosed as having lepromatous leprosy 2 years ago, was receiving multidrug therapy in the form of dapsone (100 mg/d), rifampicin (600 mg once a month), and clofazimine (300 mg once a month, and 50 mg/d). He presented to us for continuation of multidrug therapy, as he had moved. On examination, in addition to the thickening of the ulnar, common peroneal, and

Funding sources: no external funding. Conflicts of interest: none to declare. Dear Editor, A 36‐year‐old white male with untreated HIV infection presented with fever and a 2‐month history of erythematous scaly plaques affecting his palms and soles. All nail plates showed significant involvement, with Beau's lines, distal amber discoloration and onychomadesis. Treponemal and nontreponemal tests were positive, confirming a diagnosis of secondary syphilis. Normal nail regrowth was observed after penicillin treatment. Nail involvement in syphilis, despite being known for centuries, has been poorly described in recent literature. Its manifestations include opacity and amber discoloration of the nail plates, pitting, onycholysis, onychomadesis, elkonyxis, Beau's lines and paronychia.1,2

Beau's lines are transverse depressions or ridgings of the nail surface that are the result of the temporary arrest of nail matrix formation. They are caused by systemic diseases, local trauma, drugs, and infection. Generally, Beau's lines after a fingertip injury occur on only the affected finger, not on the unilateral extremity. In this report, we present the case of a 36-year-old man who developed transverse ridgings in the nail plates of all five fingers of the affected extremity after a fingertip (thumb) crushing injury. During the follow up, the growth rate of affected fingernails was normal. The transverse ridgings advanced with the linear growth of the nails and eventually disappeared. To the best of our knowledge, no association between unilateral Beau's lines and fingertip injury has been reported in the English literature.

Retronychia is a form of post-traumatic ingrowing nail disease that involves proximal nail plate embedding into the proximal nail fold, with multiple generations of nail plate beneath the proximal nail. This disease is probably underdiagnosed because of incomplete clinical forms. The aim of this study was to report clinical and aetiological variants of retronychia and to evaluate their therapeutic outcome. A retrospective review was performed on 18 patients who were seen in our institution between 2007 and 2013. The diagnostic criteria for retronychia were paronychia and interruption of nail growth. A female predominance (83.3%) was reported. Various precipitating factors were found, including traumatisms in 10 patients (55%), pregnancy and postpartum period in two patients (11%), and compartment syndrome in one patient (5%). The mean duration of paronychia was eight months (15 days to four years). The fingers most affected were the great toes. Retronychia occurred bilaterally in five cases (27%) and unilaterally in one case (61%). The commonest signs were, in decreasing order, xanthonychia (yellow discolouration of nail plate), longitudinal nail over-curvature, swelling of proximal nail fold, elevation of the proximal nail plate, granulation tissue, subungual hyperkeratosis, superficial leuconychia, distal onycholysis, subungueal haemorrhage, and Beau's lines. Most of the cases improved after proximal nail plate avulsion. Recurrence occurred in three cases (16.6%). In our opinion, ischaemic damage is the main cause of retronychia. Evaluation of clinical variants is mandatory to propose appropriate treatment. The limitations of this study include the retrospective design.