Visual Diagnosis: Spoon Nails and Short, Brittle Hair in a 3-year-old Boy

Eric P. Sorensen; Wynnis L. Tom

doi:10.1542/pir.2015-0073

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Eric P. Sorensen, MD*
Wynnis L. Tom, MD^†

^*School of Medicine, University of California, San Diego, La Jolla, CA.
^†Departments of Dermatology and Pediatrics, University of California, San Diego and Rady Children’s Hospital, San Diego, CA.

AUTHOR DISCLOSURE
Mr Sorensen and Dr Tom have disclosed no financial relationships relevant to this article. This commentary does contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentation

A 3-year-old boy presents for evaluation of toenails that have been abnormally shaped since infancy and areas of hair on the scalp that are of a coarser texture and that “never grow long at all.” There is no history of chemical or other insult to the hair or nails. He has no known health problems and has been meeting growth and developmental milestones appropriately. His pediatrician recommended a trial of sulfur sulfacetamide shampoo to the scalp, but there was no improvement. His older sister had similar hair findings that resolved by age 1 year. The boy’s mother is concerned if there might be nutritional or other health concerns because his condition has not improved. There is no other family history of hair or nail abnormalities.

On physical examination, the well-developed and well-nourished boy has appropriate behavior for age. All of his toenails are thin and depressed in a concave manner (Fig 1), but all fingernails are unaffected. His hair is short, coarse, and wiry predominately on the occipital scalp (Fig 2). Hair in all other areas appears normal. The thyroid gland is not enlarged and the distal extremities are well perfused, with no clubbing or cyanosis. Several strands of hair from the affected area appear under microscopic examination in Figure 3.

Figure 1.

Thin toenails with concave curvature.

Figure 2.

A transition from normal hair to coarse, wiry hair at the occiput.

Figure 3.

A) Examination of affected and unaffected hairs with light microscopy at 4× magnification. B) An affected hair at 40× magnification.