Peer Reviewed

Photo Essay

An Atlas of Nail Disorders, Part 4

Alexander K. C. Leung, MD
Clinical Professor of Pediatrics, University of Calgary; Pediatric Consultant, Alberta Children’s Hospital, Calgary, Alberta, Canada

Benjamin Barankin, MD
Dermatologist, Medical Director and Founder, Toronto Dermatology Centre, Toronto, Ontario, Canada

Kin Fon Leong, MD
Pediatric Dermatologist, Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia

Amy Ah-Man Leung, MD
Resident Physician, Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada

Leung AKC, Barankin B, Leong KF, Leung AA-M. An atlas of nail disorders, part 34. Consultant. 2020;60(2):48-50. doi:10.25270/con.2020.02.00003

EDITOR’S NOTE: This article is part 4 of a 15-part series of Photo Essays describing and differentiating conditions affecting the nails. Parts 5 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.

Beau Lines

In 1846, Joseph Honoré Simon Beau, a Parisian cardiologist, described the evolution of transverse grooves in the nail plates of patients who had typhoid fever or other systemic diseases. The condition now bears his name. Beau lines present as grooves that run horizontally across the nail (Figure). They are often deep and multiple and move distally with the growth of the nail. These grooves result from a temporary arrest of proximal nail matrix proliferation/mitosis. Generally, the depth of the depression reflects the severity of the insult and extent of the damage, while the width of the depression indicates the duration of the insult.1-3 The distance of the Beau line from the proximal nail fold can provide an estimate of the time of the insult to the nail matrix, based on an average growth rate of 1 mm per month for toenails and 1 mm per 6 to 10 days for fingernails.2,4,5

Photo of Beau Lines


Although all 20 nails can be affected, Beau lines are most prominent in the fingernails, especially the thumbs.2 Beau lines limited to one or a few digits may occur from localized trauma to the nail matrix (eg, onychotillomania, overzealous manicuring and cuticle damage, ill-fitting footwear) or localized cutaneous disease (eg, paronychia, dermatitis). When multiple nails are affected, the condition is often the result of an infection (eg, typhoid fever, hand-foot-and-mouth disease, herpangina, mumps, syphilis, malaria), medication (eg, chemotherapeutic agent, retinoid), systemic disease (eg, Kawasaki disease, Raynaud disease, renal disease, pemphigus, diabetes mellitus, hyperparathyroidism), myocardial infarction, or aluminum phosphide poisoning.4,6-13 At times, the condition can be idiopathic.

Treatment should be directed to the underlying etiology. Provided that the underlying cause can be eliminated, patients can be reassured that the nail changes generally resolve as new nails grow.1,6


  1. Chu N-S, Wu I-C, Chen L-T, Chin Y-Y. Beau’s lines in nails: an indicator of recent docetaxel and 5-FU use. Kaohsiung J Med Sci. 2018;34(3):181-183. doi:10.1016/j.kjms.2017.09.008 
  2. Goraya JS, Kaur S. Beau lines. J Pediatr. 2014;164(1):205. doi:10.1016/j.jpeds.2013.08.032 
  3. Ryu H, Lee HJ. Beau’s lines of the fingernails. Am J Med Sci. 2015;349(4):​363. doi:10.1097/MAJ.0000000000000244 
  4. Chang C-C, Wu C-C. Beau’s lines. QJM. 2013;106(4):383. doi:10.1093/qjmed/hcs050 
  5. Lipner SR, Scher RK. Evaluation of nail lines: Color and shape hold clues. Cleve Clin J Med. 2016;83(5):385-391. doi:10.3949/ccjm.83a.14187 
  6. Braswell MA, Daniel CR III, Brodell RT. Beau lines, onychomadesis, and retronychia: a unifying hypothesis. J Am Acad Dermatol. 2015;73(5):849-855. doi:10.1016/j.jaad.2015.08.003
  7. Chiu H-H, Liu M-T, Chung W-H, et al. The mechanism of onychomadesis (nail shedding) and Beau’s lines following hand-foot-mouth disease. Viruses. 2019;11(6):522. doi:10.3390/v11060522 
  8. Eyer-Silva WA, Silva GAR, Ferry FRA. Olecranon bursitis, Beau’s lines, Biett’s collarettes, and crown of Venus. Am J Trop Med Hyg. 2017;96(2):261-262. doi:10.4269/ajtmh.16-0386
  9. Hoy NY, Leung AKC, Metelitsa AI, Adams S. New concepts in median nail dystrophy, onychomycosis, and hand, foot, and mouth disease nail pathology. ISRN Dermatol. 2012;2012:680163. doi:10.5402/2012/680163
  10. Losa I. Beau’s lines in postpartum period and hyperparathyroidism. BMJ Case Rep. 2013;2013:bcr2013201220. doi:10.1136/bcr-2013-201220
  11. Nakhaee S, Zamani N, Mehrpour O. Beau lines and telogen effluvium following aluminium phosphide poisoning. N Z Med J. 2019;132(1491):90-92. 
  12. Rich P. Overview of nail disorders. UpToDate. Updated December 5, 2019. Accessed January 8, 2020.
  13. Shin JY, Cho BK, Park HJ. A clinical study of nail changes occurring secondary to hand-foot-mouth disease: onychomadesis and Beau’s lines. Ann Dermatol. 2014;26(2):280-283. doi:10.5021/ad.2014.26.2.280


NEXT: Onychomadesis


Onychomadesis, also known as defluvium unguium, refers to the spontaneous separation of the nail plate from the matrix starting at the proximal end. The condition is the result of temporary complete halt in proximal nail matrix proliferation/mitosis.1 

Compared with Beau lines, the insult to the nail matrix is more severe and/or prolonged. It is possible that the quality of the newly formed nail may be temporarily altered, leading to separating of the nail plate.1 As the new nail begins its growth proximally, it extends underneath the previous nail, pushing the previous nail forward, resulting in a whole thickness sulcus that splits the nail plate into two parts (Figure) with eventual shedding of the previous nail.1,2 Typically, the condition is self-limited and painless.1 Onychomadesis may occur in fingernails and/or toenails.

Photo of onychomadesis

Onychomadesis has been shown to be associated with infections (notably hand-foot-and-mouth disease, varicella, and scarlet fever), local cutaneous diseases (eg, onychomycosis, paronychia), direct trauma to the nail matrix (eg, from ill-fitting, closed-toe shoes with a narrow toe box; fingertip crush injury; repetitive friction from long-distance running; hand trauma; wrist fracture; fish pedicures), allergic contact dermatitis, systemic medical illnesses (eg, Kawasaki disease, Steven-Johnson syndrome, toxic epidermal necrolysis, lichen planus, Cronkhite-Canada syndrome, Guillain-Barré syndrome, myocardial infarction, renal failure, meningitis, immunodeficiency), use of medications (eg, chemotherapeutic agents [eg, doxorubicin, capecitabine, mycophenolic acid, etoposide, cytosine arabinoside, vincristine], use of antibiotics [eg, penicillin, cloxacillin, azithromycin, cephalosporin], use of antiepileptics [eg, valproic acid, carbamazepine], retinoids, lithium, indinavir), autoimmune diseases (eg, systemic lupus erythematosus, alopecia areata, pemphigus vulgaris, linear immunoglobulin A disease), nutritional deficiency (ie, minerals and vitamins), lead poisoning, and chronic selenium toxicity.1,3-16 

When only one or a few nails are involved, onychomadesis is most likely secondary to a local cutaneous disease or direct trauma to the nail matrix.17,18 Rarely, onychomadesis can be familial or idiopathic.2,6,17

Neonatal onychomadesis may result from birth trauma and perinatal stressors. Onychomadesis affecting both great toenails with onset in early childhood may be due to congenital malalignment of the great toenails.17 Hemorrhagic onychomadesis is a cutaneous clue to chronic selenium toxicity.11 Pain preceding onychomadesis suggests a traumatic or inflammatory cause.17 Because of the slow growth of toenails, recalling the causative insult can be difficult.17 The diagnosis is mainly clinical through inspection and palpation of the nail plate.

In most cases, the prognosis is excellent.18 New nail growth will be normal if the inciting agent is removed or the insulting illness resolves. Occasionally, onychomadesis may be complicated by onychomycosis, in particular a yeast infection, because shedding of the nail plate impairs its protective function and provides localities for settling of pathogens.19


  1. Leung AKC, Leong KF, Lam JM. Onychomadesis in a 20-month-old child with Kawasaki disease. Case Rep Pediatr. 2019;2019:3156736. doi:​10.1155/2019/3156736
  2. Feng C-W, Chen H-C, Lu C-C. Mycophenolic acid-induced onychomadesis: an easily ignorable adverse effect in patients with rheumatic diseases. Int J Rheum Dis. 2019;22(4):753-755. doi:10.1111/1756-185X.13544 
  3. Braswell MA, Daniel CR III, Brodell RT. Beau lines, onychomadesis, and retronychia: a unifying hypothesis. J Am Acad Dermatol. 2015;73(5):849-855. doi:10.1016/j.jaad.2015.08.003
  4. Deeb M, Beach RA, Kim S. Onychomadesis following hand, foot, and mouth disease in a pregnant woman: a case report. SAGE Open Med Case Rep. 2019;7:2050313X19845202. doi:10.1177/2050313X19845202
  5. Di Biagio A, Taramasso L, Gustinetti G, Riccardi N, Viscoli C. Onychomadesis in a male patient with secondary syphilis. Int J STD AIDS. 2016;27(8):​704-705. doi:10.1177/0956462416628703
  6. Grover C, Vohra S. Onychomadesis with lichen planus: an under-recognized manifestation. Indian J Dermatol. 2015;60(4):420. doi:10.4103/0019-5154.160512
  7. Güler S, Işık İ, İşcan A. Onychomadesis: a rare adverse effect in early-period valproic acid therapy. Turk Pediatri Ars. 2017;52(2):98-100. doi:10.5152/TurkPediatriArs.2015.2630
  8. Hardin J, Haber RM. Onychomadesis: literature review. Br J Dermatol. 2015;172(3):592-596. doi:10.1111/bjd.13339
  9. Hoy NY, Leung AKC, Metelitsa AI, Adams S. New concepts in median nail dystrophy, onychomycosis, and hand, foot, and mouth disease nail pathology. ISRN Dermatol. 2012;2012:680163. doi:10.5402/2012/680163
  10. Podder I, Das A, Gharami RC. Onychomadesis following varicella infection: is it a mere co-incidence? Indian J Dermatol. 2015;60(6):626-627. doi:10.4103/0019-5154.169152
  11. Razmi TM, Attri SV, Handa S. Haemorrhagic onychomadesis: a cutaneous clue to chronic selenosis – case series. J Eur Acad Dermatol Venereol. 2017;31(9):e425-e427. doi:10.1111/jdv.14241
  12. Sechi A, Chessa MA, Leuzzi M, Neri I. Onychomadesis: a rare skin sign occurring after chickenpox. Indian J Dermatol. 2018;63(3):272-273. doi:​10.4103/ijd.IJD_429_17
  13. Sukakul T, Varothai S. Chronic paronychia and onychomadesis in pemphigus vegetans: an unusual presentation in a rare autoimmune disease. Case Rep Med. 2018;2018:5980937. doi:10.1155/2018/5980937
  14. Yamaguchi Y, Hoshina D, Furuya K. Onychomadesis caused by efinaconazole. Contact Dermatitis. 2017;76(1):57-58. doi:10.1111/cod.12658
  15. Yüksel S, Evrengül H, Özhan B, Yüksel G. Onychomadesis—a late complication of hand-foot-mouth disease. J Pediatr. 2016;174:274. doi:10.1016/j.jpeds.2016.03.073
  16. Lipner SR. Onychomadesis following a fish pedicure. JAMA Dermatol. 2018;154(9):1091-1092. doi:10.1001/jamadermatol.2018.1827
  17. Pearson HJ, Brodell RT, Daniel CR III. Seasonal onychomadesis of the great toes. Skin Appendage Disord. 2018;4(3):177-179. doi:10.1159/000484328
  18. Suchonwanit P, Nitayavardhana S. Idiopathic sporadic onychomadesis of toenails. Case Rep Dermatol Med. 2016;2016:6451327. doi:10.1155/2016/​6451327
  19. Li M, Chen Z, Yin S, et al. Onychomycosis secondary to onychomadesis: an underdiagnosed manifestation. Mycoses. 2017;60(3):161-165. doi:​10.1111/myc.12555