Transient subungual erythema in a patient with idiopathic Sweet’s syndrome

Abstract

To the Editor: Dermatosis-related nail involvement has not been described in patients with Sweet's syndrome. We report a 35-year-old woman in whom idiopathic Sweet's syndrome and subungual erythema concurrently developed. Both conditions promptly resolved after corticosteroid therapy was initiated. A 35-year-old woman was referred to our department because of a 5-day history of cutaneous lesion associated with fever, arthralgia, and myalgia. At the same time, she noticed changes in the color of her fingernails. Examination showed multiple erythematous papules and plaques on the upper extremities, the neck (Fig 1), and the forehead. Subungual erythema was present on digits II, III, and V of the right hand and digits II, III, IV, and V of the left hand. This erythema extended into the proximal two thirds of the nail bed with incomplete involvement of the lunula (Fig 2). Distal splinter hemorrhages were also present on the nails of digit II of the right hand and digits II and III of the left hand. The skin biopsy specimen from a papule showed edema of the dermal papillae and a dense infiltrate of neutrophils without vascular damage. There was neutrophilia (leukocyte count, 6.1 x 109/1 with 77% neutrophils), an increased erythrocyte sedimentation rate (75 mm/h), and increased C-reactive protein (7.20 mg/dL; N < 0.7). These findings fulfilled the diagnostic criteria for idiopathic Sweet's syndrome.1Hônigsmann H. Cohen P.R. Wolff K. Acute febrile neutrophilic der-matosis (Sweet's syndrome).Fitzpatrick's dermatology in general medicine. 1999; Vol 1 (5th ed): 1117-1123Google Scholar The patient recovered rapidly after treatment with corticosteroid therapy and the red color of her fingernails disappeared in 10 days. Three weeks later, her nails were yellowish in color. The patient remains asymptomatic, without treatment, after 12 months.Fig 2Subungual erythema on digits II, III, IV, and V of left hand.View Large Image Figure ViewerDownload (PPT) The temporal relationship between the onset and resolution of our patient's dermatosis and subungual erythema raises the possibility that her nail involvement was associated with Sweet's syndrome. Subungual erythema has also been described in various conditions as the half-and-half nail phenomenon, occurring mainly in those with chronic renal failure but also in healthy patients.2Lubach D. Strubbe I. The incidence of subungual erythema.Z Hautkr. 1982; 57: 1487-1495PubMed Google Scholar Erythema is present on the distal portion of the nail bed and is well demarcated from the proximal portion. This form is often permanent, in contrast to the course of our patient. Subungual erythema may also correspond to recent subungual hematomas after trauma or in patients receiving anticoagulant therapy, and in elderly patients in various conditions.3Cohen P.R. Scher R.K. Geriatric nail disorders: diagnosis and treatment.J Am Acad Dermatol. 1992; 26: 521-531Abstract Full Text PDF PubMed Scopus (75) Google Scholar Clinical history and rapid resolution in our case do not favor these alternatives. Medication-related subungual erythema has been observed in patients receiving drugs such as clofazimine4Dixit V.B. Chaudary S.D. Jain V.K. Clofazimine induced nail changes.Indian J Lepr. 1989; 61: 476-478PubMed Google Scholar or cancer chemotherapeutic agents.5Pavithran K. Doval D.C. Nail changes due to docetaxel.Br J Dermatol. 2002; 146: 709-710Crossref PubMed Scopus (27) Google Scholar It may be secondary to drug-induced photo-onycholysis as well.6Baran R. Juhlin L. Drug-induced photo-onycholysis: three subtypes identified in a study of 15 cases.J Am Acad Dermatol. 1987; 17: 1012-1016Abstract Full Text PDF PubMed Scopus (80) Google Scholar However, our patient had not received any drug before her episode of Sweet's syndrome. In this observation, subungual erythema extending into the proximal two thirds of the nail bed with incomplete involvement of the lunula may be a particular localization of Sweet's syndrome, however, no biopsy specimen was taken to confirm this hypothesis.