Landa et aL eases including two patients with monoclonal patterns and subsequent lymphoma. Cancer 1982;49:2049-69. 23. Stevanovie G, Cramer AD, Taylor CR, et al. Immunoblastic sarcoma in patients with systemic lupus erythematosas--like disorders. Arch Pathol Lab Med 1983;107: 589-92. 24. Palutke M, Schnitzer B, Mirchandani I, et aI. Increased numbers of lymphocytes with single class surface immuno-
Journal of the American Academy of Dermatology
globulins in reactive lymphoidhyperplasia of lymphoid tissue. Am J Clin Pathol 1982;78:316-23. 25. Levy N, Nelson J, Meyer P, et al. Reactive lymphoid hyperplasia with single class (monoclonal) surface immunoglobulin. Am J Clin Pathol 1983;80:300-8. 26. Fishleder A, Tubbs R, Hesse B, et al. Uniform detection of immunoglobulin-generearrangement in benign lymphoepithelial lesions. N Engl J Med 1987;316:I 118-21.
Red lunulae: Case report and literature review Philip R. Cohen, M D Houston, Texas Thumb nails with asymptomatic red lunulae were noted in a 54-year-old woman with testosterone propionate-responsive vulvar lichen sclerosus et atrophicus of 4 years' duration and locafized vitiligo that had been treated with topical corticosteriods for 15 months. Cutaneous and systemic disorders in which red lunulae have been observed are reviewed. (J AM ACAD DERMATOL 1992;26:292-4.) R e d lunulae h a v e been observed in patients with several cutaneous or systemic disorders (Table I). l-l~ Although its cause has not been definitively established, some patients with this nail change had an underlying a u t o i m m u n e condition, had received corticosteroid therapy, or both. I report a w o m a n with red lunulae o f the t h u m b nails and review the disorders in which red lunulae have been described. CASE R E P O R T A 54-year-old Latin American woman recently noticed a change in the color of her thumb nails. Examination showed that the proximal lunulae of both thumb nails were reddish-pink in color; a thin band of colorless to white, normal-appearing lunula was present distal to the discoloration (Fig. 1). The nail plate overlying the nail bed distal to the nail matrix had a normal appearance. Biopsy-confirmed vulvar lichen sclerosus et atrophicus had been diagnosed 4 years previously and was being treated topically with 2% testosterone propionate in petrolatum. Fifteen months ago the patient had noticed white spots on her axillae, wrists, neck, and perineal area; examination with a Wood's light had demonstrated macFromthe Departmentsof Dermatologyand Pathology,The University of Texas Medical Schoolat Houston. Reprint requests:PhilipR. Cohen, MD, Departmentof Dermatology, The Universityof Texas MedicalSehool,6431 Fannin,Suite 1.204, Houston,Texas 77030. 16/4/31551
Fig. 1. Thumb nails with red lunulae. Reddish-pink discoloration of lunula extends from proximal nail fold and is bordered distally by a thin colorless to white band of normal-appearing lunula. ular areas of depigmentation consistent with vitiligo. Results of thyroid function tests were normal. The areas of vitiligo were treated topically twice daily with 0.05% fluocinonide cream. Initially there was partial repigmentation of the vitiliginous areas. Subsequently these areas
Volume 26 Number 2, Part 2 February 1992
R e d lunulae
Table I. Disorders in patients with red lunulae Cardiovascular1"4 Angina pectoris 1,2 Atherosclerotic diseasd, 3 Conduction abnormality3 Congestive heart failure l Hypertension2-4 Myocardial infarction1, 2 Rheumatic fever-induced heart diseasea Dermatologic3, 5-9 (also this case) Alopecia areata s'7 Chronic urticaria 3 Lichen sclerosus et atrophicus (this case) Psoriasis vulgaris 3, 8 Twenty nail dystrophy9 Vitiligo (this case) Endocrine2, 3 Diabetes rnellitus 3 Thyroid diseasea, 3 Hyperthyroidism2 Not specified 3 Gastrointestinal3 Esophageal strictures a Irritable bowel syndrome3 Pyloric channel ulcer3 Hematologic3 Anemia of chronic disease3 Idiopathic transient leukopenia 3 Hepatic 2, 3 Cirrhosis 2, 3 Infectious1-3 Lymphogranuloma venereum 1 Pneumonia3 Tuberculosis 2
either persisted or increased in size, and new areas of depigmentation appeared. DISCUSSION Patients with various disorders (cardiovascular, l4cutaneous,3, 5-9endocrine,Z 3gastrointestinal,3 hematologic, 3 hepatic, z3 infectious, 1-3 miscellaneous, 2-5,7,8 [email protected]
, 2 neurologic, 3 pulmonary,2, 3 renal,3 and rheumatologic 3, 4, 10) have been reported in whom the lunulae of one or more nails of the hands, feet, or both were red. In patients with red lunulae, a narrow white band m a y be present at the distal lunulae proximal to the pink nail bed.
Miscellaneous24, 7,8 (also this case) Alcohol abuse3 Carbon monoxide poisonings Chronic idiopathic lymphedema3 Corticosteroid therapy3"5 (also this case) Systemic3-5 Topical (this case) Hay fever pollen desensitization7 Malnutritionz Tobacco abuse 3 Senile macular degeneration3 Neoplastid, 2 Hodgkin's disease2 Lymphoid follicular reticulosis2 Lymphosarcoma1 Myeloid leukemia2 Polycythemia vera2 Reticulosarcoma 1 Neurologic3 Cerebrovascular accident3 Pulmonary2, 3 Chronic bronchitis: Chronic obstructive pulmonary disease 3 Emphysema2 Renal a Proteinuria 3 Rheumatologic3, 4, to Baker's cyst4 Dermatomyositis4 Lupus erythematosus3, 4 Drug-induced (proeainamide) 3 Systemic4 Osteoarthritis 3, 4 Polymyalgia rheumatica 3 Rheumatoid arthritis 3, 4, lo
The disorders listed in Table I represent either current or inactive conditions that have been described in patients with red lunulae, l l ~ Whether a significant association exists between each of these conditions and red lunulae remains to be determined. The first description of patients with red lunulae was by Terry 2 in 1954. H e reported 23 patients with various underlying medical disorders in whom the lunulae of their fingernails were suffused or red. All patients were at least 40 years of age; 87 % were men. Terry noted that 14 patients (61%) h a d a cardiovascular disorder. ARhough he did not consider the in-
Journal of the American Academy of Dermatology
294 Cohen cidence of red lunulae to be rare, Terry had not observed them in a group of 150 healthy women or in patients with hernias or peptic ulcer disease.2 Shortly thereafter, Leider5 and Ringrose and BahcaU6 reported red lunulae in two patients with alopecia areata. After systemic corticosteroid therapy had been initiated in the first patient, the normal whiteness of the lunulae was eventually replaced by erythema in the fingernails and toenails; the red lunulae persisted after the medication was discontinued.5 In the second patient with alopecia areata, the lunulae of only the thumbs and great toes revealed a dusky erythematous discoloration; that patient had not received corticosteroid therapy. 6 Subsequently a third patient with extensive alopecia areata developed a dusky red discoloration that involved all 20 lunulae and was most evident in the thumbs. 7 There had been no previous treatment with corticosteroids; the nail changes had occurred during the patient's second desensitizing course for pollen hay fever. Pitting of several nails was also present, and marked nail dystrophy subsequently developed] In addition to alopecia areata, s'7 red lunulae have also been observed in patients with other autoimmune conditions. These include endocrine2, 3 and rheumatologic3, 4, ~o disorders. My patient had vitiligo; red lunulae have not previously been described in patients with this condition.ll Several patients in whom red lunulae developed, including the patient in this report, had previously received or were being treated with corticosteroid for another disorder: alopecia areata, s chronic obstructive pulmonary disease, 3dermatomyositis,4rheumatoid arthritis, 4 or vitiligo (this report), or for the relief of musculoskeletal symptoms in a patient with procainamide-induced lupus erythematosus who had a history of polymyalgia rheumatica and osteoarthritis. 3 Five of these patients had received their corticosteroids systemically34; one, topically (this report). Red lunulae appeared within 2 weeks after corticosteroid therapy was initiated in one patient.5 For most patients, unfortunately, the duration of treatment with corticosteroids before the development of red lunulae was not indicated), 4 The pathogenesis of red lunulae remains undetermined. Terry 6 postulated that red lunulae result
from an abnormally increased adhesion of the superficial layer of the nail bed to the nail plate. Other possibilities include the formation of telangiectasis resulting from a proliferation of capillaries in the lunulae or the normal blood vessels merely becoming more apparent because of a change in the optical properties of the overlying nail plate. The former possibility is less likely because histologic evaluation of a biopsy specimen taken from the red lunula of a thumb revealed neither an increased number nor size of capillaries; in addition, telangiectasis was absent, and other abnormalities were not observed) Jorizzo et al.,4 did not attribute the red lunulae in their patient with rheumatoid arthritis to be a manifestation of rheumatoid vasculitis. Instead, they emphasized the similarity of their patient's red lunulae to the palmar erythema seen in patients with rheumatoid arthritis. 4 Wilkerson and Wilkin3 suggested that red lunulae are caused by either a venous vasodilatory capacitance phenomenon of uncertain origin or by an increased arteriolar blood flow in that area. REFERENCES
1. DeNicola P, Morsiani M, Zavagli G. Nail diseases in internal medicine. Springfield, Illinois: Charles C Thomas, 1974:56. 2. Terry R. Red half-moons in cardiac failure. Lancet 1954; 2:842-4. 3. Wilkerson MG, Wilkln JK. Red lunulae revisited: a clinical and histopathologie examination. J AM ACADDERMATOL 1989;20:453-7. 4. Jofizzo JL, Gonzalez EB, Daniels JC. Red lunulae in a patient with rheumatoid arthritis. J AM ACAt) DERMATOL 1983;8:711-8. 5. Leider M. I. Progression of alopecia areata through alopecia totalis to alopeeia generalizata. II. Peeular nail changes (obliteration of the lunulae by erythema) while under cortisone therapy. III, Allergic eczematous contact dermatitis from the binding of a toupee or the adhesive used to hold it in position. Arch Dermatol 1955;71:648-9. 6. Ringrose EJ, BahcaU CR. Alopecia symptomatiea with nail base changes. Arch Dermatol 1957;76:263-4. 7. Miseli KJ. Red nails associated with alopeeia areata. Clin Exp Dermatol 1981;6:561-3. 8. Daniel CR III. Nail pigmentation abnormalities. Dermatol Clin 1985;3:431-43. 9. Runne V, Twenty-nail dystrophy "mit knuckle pads." Z Hautk_r 1980;55:901-2. 10. Daniel CR III, Sams WM Jr, Scher RK. Nails in systemic disease. Dermatot Clin 1985;3:465-83. 11, Barth JH, Telfer NR, Dawber RPR. Nail abnormalities and autoirnmunity. J AM ACAD DERMATOL 1988;18: 1062-5.