Peer Reviewed

Photo Essay

An Atlas of Nail Disorders, Part 12

Alexander K. C. Leung, MD1,2 • Benjamin Barankin, MD3 • Kin Fon Leong, MD4

1Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
2Alberta Children’s Hospital, Calgary, Alberta, Canada
3Toronto Dermatology Centre, Toronto, Ontario, Canada
4Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia

Leung AKC, Barankin B, Leong KF. An atlas of nail disorders, part 12. Consultant. 2020;60(10):22-24. doi:10.25270/con.2020.10.00002

The authors report no relevant financial relationships.

Alexander K. C. Leung, MD, #200, 233 16th Ave NW, Calgary, AB T2M 0H5, Canada (

This article is part 12 of a 15-part series of Photo Essays describing and differentiating conditions affecting the nails. Parts 13 through 15 will be published in upcoming issues of Consultant. To access previously published articles in the series, visit the Consultant archive at and click the “Journals” tab.


Nail Changes in Lichen Planus

The term lichen planus derives from the Greek word leikhen, meaning “tree moss,” and the Latin word planus, meaning “flat.” Lichen planus is an inflammatory dermatosis of unknown origin that typically affects the skin, mucous membranes, and nails.1 One or several areas can be involved, either concomitantly or sequentially.1,2

The prevalence of lichen planus has been estimated to be 1% in the United States.3 Both sexes are equally affected.3,4 Most cases occur in individuals between 30 and 60 years of age.4,5 The exact etiology is not known. An immune-mediated mechanism involving activated T cells, in particular CD8+ T cells, directed against basal keratinocytes, is believed to be responsible.6,7 Infectious, genetic, and environmental factors may also play a role.6,8

Cutaneous lichen planus is the most common presentation, characterized by the 6 P’s: planar (flat-topped), purple (violaceous), polygonal, pruritic, and papules/plaques that affect the skin.1,5 Individual papules may coalesce to form plaques.7 Lesions of lichen planus are often superimposed by lacy, reticular, white streaks known as Wickham striae.2,5 Sites of predilection include the flexor aspects of the wrists and ankles, the dorsa of hands, trunk (Figure 1), the shins, and the glans penis (Figure 2).1,3,9,10 The distribution is often symmetric.1 Similar to psoriasis, the Koebner phenomenon is particularly characteristic, which often occurs as a result of scratching.1,5,7

Fig 1
Figure 1. Lichen planus on a patient’s trunk.

Fig 2
Figure 2. Lichen planus on a patient’s glans penis.

There are 3 main forms of oral lichen planus, namely, reticular, erosive, and atrophic.5 The reticular form is most common and typically presents as bilateral, asymptomatic papules or plaques with interlacing Wickham striae on the oral mucosa.11 The erosive form presents as ulceration, erythema, and keratotic areas.1 Erosive lesions can be quite painful. The atrophic form typically presents as a red, diffuse lesion with mucosal atrophy.1

Approximately 10% of patients with lichen planus have nail involvement.4,12 Isolated nail lichen planus, on the other hand, is rare.8 Nail involvement is more commonly observed in adults and typically affects multiple or all nails without necessarily affecting the nearby skin.6,12 Generally, fingernails are more frequently affected than toenails.4 Nail lichen planus is characterized by nail plate thinning, longitudinal ridging, longitudinal nail fissuring, onycholysis, onychorrhexis, trachyonychia, erythema of the lunula, nail atrophy with koilonychia, and, in severe cases, dorsal pterygium and anonychia (Figures 3-7).1,10,13,14

Fig 3
Figure 3.

Fig 4
Figure 4.

Fig 5
Figure 5.

Fig 6
Figure 6.

Fig 7
Figure 7.

Subungual hyperkeratosis might be present.12 Dermoscopy often shows pitting of the nail matrix and trachyonychia in the early stage, and lamina fragmentation, chromonychia, onycholysis, and splinter hemorrhage at a later stage.4 The diagnosis is mainly clinical, based on the characteristic physical findings. In case of doubt, biopsy of the nail matrix should be considered. Histological findings include hyperkeratosis, irregular epidermal hyperplasia, hypergranulosis, necrotic keratinocytes, and dense lichenoid lymphohistiocytic infiltrate with melanophages.8,15


  1. Leung AKC, Barankin B. Lichen planus. Consultant. 2014;54(2):137-138. Accessed September 8, 2020.
  2. Le Cleach L, Chosidow O. Clinical practice. Lichen planus. N Engl J Med. 2012;366(8):723-732. doi:10.1056/NEJMcp1103641
  3. Lehman JS, Tollefson MM, Gibson LE. Lichen planus. Int J Dermatol. 2009;48(7):682-694. doi:10.1111/j.1365-4632.2009.04062.x
  4. Weston G, Payette M. Update on lichen planus and its clinical variants. Int J Womens Dermatol. 2015;1(3):140-149. doi:10.1016/j.ijwd.2015.04.001
  5. Usatine RP, Tinitigan M. Diagnosis and treatment of lichen planus. Am Fam Physician. 2011;84(1):53-60. Accessed September 8, 2020.
  6. Arnold DL, Krishnamurthy K. Lichen planus. StatPearls. Updated August 10, 2020. Accessed September 8, 2020.
  7. Goldstein BG, Goldstein AO, Mostow E. Lichen planus. UpToDate. Updated June 27, 2019. Accessed September 8, 2020.
  8. Tziotzios C, Lee JYW, Brier T, et al. Lichen planus and lichenoid dermatoses: Clinical overview and molecular basis. J Am Acad Dermatol. 2018;79(5):789-804. doi:10.1016/j.jaad.2018.02.010
  9. Leung AKC, Barankin B, Leong KF, Hon KL. Penile warts: an update on their evaluation and management. Drugs Context. 2018;7:212563. doi:10.7573/dic.212563
  10. Murynka T, Prajapati V, Barankin B. Dermacase. Can you identify this condition? Nail lichen planus. Can Fam Physician. 2009;55(12):1207-1208. Accessed September 8, 2020.
  11. Au J, Patel D, Campbell JH. Oral lichen planus. Oral Maxillofac Surg Clin North Am. 2013;25(1):93-100. doi:10.1016/j.coms.2012.11.007
  12. Rich P. Overview of nail disorders. UpToDate. Updated December 5, 2019.
  13. Leung AKC, Leong KF, Barankin B. Trachyonychia. J Pediatr. 2020;216:239-239.e1. doi:10.1016/j.jpeds.2019.08.034
  14. Lipner SR. Nail lichen planus: a true nail emergency. J Am Acad Dermatol. 2019;80(6):e177-e178. doi:10.1016/j.jaad.2018.11.065
  15. Baran L-R. Yellow nail syndrome and nail lichen planus may be induced by a common culprit. Focus on dental restorative substances. Front Med (Lausanne). 2014;1:46. doi:10.3389/fmed.2014.00046