Published Date: 2010-09-16 14:00:05
Subject: PRO/EDR> Onychomadesis and hand, foot & mouth disease, link?
Archive Number: 20100916.3356
ONYCHOMADESIS AND HAND, FOOT AND MOUTH DISEASE, LINK?
A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases
Date: Thu 16 Sep 2010
Source: Eurosurveillance, Volume 15, Issue 37 [edited]
Onychomadesis and hand, foot and mouth disease - is there a
connection? By: E Haneke. At: Dermatology Practice "Dermaticum,"
Freiburg, Germany; Department of Dermatology, Inselspital, University
of Bern, Bern, Switzerland; Dermatology Centre "Epidermis;" Instituto
CUF, Porto, Portugal; Department of Dermatology, Academic Hospital,
University of Ghent, Ghent, Belgium
Onychomadesis is the spontaneous separation of the nail plate from
the matrix, a kind of proximal onycholysis, and is a common
phenomenon due to arrest of nail formation for a certain period.
Short-term slowing down of nail formation leads to Beau's lines,
while long-term stop of nail growth will cause onychomadesis and even
Hand, foot and mouth disease (HFMD) is a relatively common viral
infection often seen as small epidemics in autumn or spring [In fact,
in south-east Asian countries, epidemics of HFMDV characteristically
involve large numbers of infants, are socially disruptive, and
responsible for a number of fatalities. - Mod.CP]. It is
characterised by oval blisters around the nails, on palms and soles
with the long axis of the vesicles running along the dermatoglyphs,
and by aphthoid small ulcerations of the oral mucosa. Small children
are mostly infected, but probably many parents are non-symptomatic
carriers as the condition usually runs a very mild course.
A relationship between HFMD and onychomadesis has been proposed
already 10 years ago [1,2], but only recently Finnish and Spanish
authors observed a sufficient number of children developing
onychomadesis approximately 6 weeks after they had suffered from HFMD
[3-6] that makes this appear more than a chance association. An
article by Guimbao and coworkers published in today's [16 Sep 2010]
issue of Eurosurveillance [see (2) below] describes an outbreak of
onychomadesis in Saragossa (Spain) in July 2008 . The authors
noticed that a large proportion of the patients had had HFMD a few
weeks before and initiated a retrospective cohort study that
indicated a link between the 2 diseases. They conclude that
onychomadesis may be a late complication of HFMD.
From these authors' and the previous ones' observations, there is no
doubt that there is a temporal link between HFMD and onychomadesis.
The question is now: Is the virus, more specifically the enterovirus
causing HFMD, really the cause of onychomadesis? While the number of
onchomadesis cases in these young patients suggests it, could it have
been caused rather by the inflammation so close to the nail matrix?
Or could it have been due -- of course much less likely -- to
intensive hygienic measures taken after HFMD broke out in the
nurseries? It is well known that maceration favours Candida
infections and allergic contact dermatitis, which can also cause
onychomadesis . The timing of viral determination from stools and
pharynx samples taken one to 3 weeks after the diagnosis of
onychomadesis and thus between 7-9 weeks after the disease, appears
to be very late considering that HFMD is a self-limited condition
healing spontaneously within a week. In order to solve the problem,
more viruses that could potentially be associated with the 2
conditions will need to be analysed, with viral analyses of nail
(e.g. swabs from under the proximal nail fold) performed in the
early course of the disease.
However, onychomadesis per se is certainly not infectious; instead,
it may be the consequence of an infectious disease often localised
very close to the nail. Another explanation would be that HFMD has a
more severe impact on the general condition of the small children so
that it causes a nail growth arrest for a period sufficiently long to
result in onychomadesis.
 Clementz GC, Mancini AJ. Nail matrix arrest following hand-foot-
mouth disease: a report of five children. Pediatr Dermatol.
 Bernier V, Labreze C, Bury F, Taieb A. Nail matrix arrest in the
course of hand, foot and mouth disease. Eur J Pediatr. 2001;160(11):
 Osterback R, Vuorinen T, Linna M, Susi P, Hyypia T, Waris M.
Coxsackievirus A6 and hand, foot, and mouth disease, Finland. Emerg
Infect Dis. 2009;15(9):1485-8.
 Redondo Granado MJ, Torres Hinojal MC, Izquierdo Lopez B. Brote
de onicomadesis posvirica en Valladolid. [Post viral onychomadesis
outbreak in Valladolid]. Spanish. An Pediatr (Barc). 2009;71(5):436-9.
 Blomqvist S, Klemola P, Kaijalainen S, Paananen A, Simonen ML,
Vuorinen T, et al. Co-circulation of coxsackieviruses A6 and A10 in
hand, foot and mouth disease outbreak in Finland. J Clin Virol.
 Davia JL, Bel PH, Ninet VZ, Bosch IF, Salazar A, Gobernado M.
Onychomadesis outbreak in Valencia, Spain associated with hand, foot,
and mouth disease caused by enteroviruses. Pediatr Dermatol. 2010 Jun
9. [Epub ahead of print]
 Guimbao J, Rodrigo P, Alberto MJ, Omenaca M. Onychomadesis
outbreak linked to hand, foot, and mouth disease, Spain, July 2008.
Euro Surveill. 2010;15(37):pii=19663. Available from:
 Tosti A, Piraccini BM. Paronychia. In: Amin S, Maibach HI.
Contact Urticaria Syndrome. Boca Raton, Florida: CRC Press; 1997.
Date: Thu 16 Sep 2010
Source: Eurosurveillance, Volume 15, Issue 37 [summarised & edited]
Onychomadesis outbreak linked to hand, foot, and mouth disease,
Spain, July 2008
Summary: In July 2008, an onychomadesis outbreak in a nursery setting
was reported in Saragossa (Spain). Some of the cases had previously
suffered from hand, foot and mouth disease (HFMD). In order to study
the outbreak and to determine the relation between the 2 diseases, 2
epidemiological studies were conducted: a descriptive study focused
on cases and a retrospective cohort study. Samples from stool,
pharynx and nails were obtained from cases for microbiological
analysis. During the study period, 27 children fulfilled the case
definition. The average age was 1.8 years. A case shed on average 4
nails (minimum one, maximum 12). 24 of the 27 cases had previously
presented with HFMD which started an average of 40 days before the
onset of onychomadesis (relative risk: 14). Unidentified non-polio
enterovirus (n=10), coxsackie B1 (n=4) and coxsackie B2 virus (n=3)
were isolated in 28 specimens obtained from 14 cases. The analysis
showed a strong association between HMFD and onycho!
madesis. Microbiological results have not been conclusive;
consequently, more studies are necessary to determine the causal
agent of infectious onychomadesis.
[Interested readers should consult the full article via the above
URL. - Mod.CP]
[HFMD epidemics have primarily been associated with different
enteroviruses, such as coxsackievirus A6, A10, and A16, echovirus 4,
enterovirus 71, and unidentified non-poliovirus enteroviruses. Those
caused by enterovirus 71 have occurred more frequently in Southeast
Asia in recent years, but onychomadesis has not been reported as a
complication of HFMD in these epidemic.
The diversity of enteroviruses associated with HFMD and the time
lapse between the acute disease and the appearance of onychomadesis
make it difficult to confirm an association. However, it may be that
HFMD is more than an acute, self-limiting febrile disease, and
further analysis is warranted. - Mod.CP]