Indian Journal of Dermatology
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Year : 2022  |  Volume : 67  |  Issue : 5  |  Page : 587-588
Unilateral nail and toe nail dystrophy in a case of hemiplegia: A rare presentation of reflex sympathetic dystrophy

1 Department of Dermatology, Military Hospital Agra, Uttar Pradesh, India
2 Department of Dermatology, MLN Medical College Prayaagraj, Uttar Pradesh, India
3 Department of Dermatology, Command Hospital Air Force Bangalore, Karnataka, India

Date of Web Publication29-Dec-2022

Correspondence Address:
Debdeep Mitra
Department of Dermatology, Command Hospital Air Force Bangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.ijd_949_21

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How to cite this article:
Saraswat N, Kumar S, Tripathy DM, Mitra D, Bhatnagar AK. Unilateral nail and toe nail dystrophy in a case of hemiplegia: A rare presentation of reflex sympathetic dystrophy. Indian J Dermatol 2022;67:587-8

How to cite this URL:
Saraswat N, Kumar S, Tripathy DM, Mitra D, Bhatnagar AK. Unilateral nail and toe nail dystrophy in a case of hemiplegia: A rare presentation of reflex sympathetic dystrophy. Indian J Dermatol [serial online] 2022 [cited 2023 Feb 8];67:587-8. Available from:


Chronic regional pain syndrome (CRPS) is a disabling, complex, poorly understood neurovascular disorder and has two subtypes. Reflex sympathetic dystrophy (RSD) (type 1) is seen following noxious events, and type 2 is seen after definitive peripheral nerve damage. Both have characteristic hyperalgesia and continuing pain. Nail changes such as leukonychia, Beau's lines, nail-fold swelling, clubbing, acute paronychia, dystrophy and trachonychia are seen.[1] Herein, we report a case of CRPS type 1 following a cerebrovascular accident in a male who presented with pain in the left half of the body and dystrophy of all fingers and toenails.

A 54-years-old male with no comorbidities was admitted with a cerebrovascular accident (CVA) resulting in hemiplegia and pain in the left half of the body. Four months later, he complained of brownish discoloration of the fingers and toenails of the left side. It was preceded by pain, redness and swelling of the left hand 2 months back [Figure 1] and [Figure 2]. Over the next 1 week, he developed similar features in the toenails. There was brittleness of the finger and toenails along with swelling and pain of the nail folds. Dermatological examination revealed increased curvature of the left great toenail, brownish discoloration and dystrophy of all the nail plates of finger and toenails with sparing of the right great toenail. Rest of his dermatological examination was normal. His routine haematological and biochemical investigations were essentially normal. KOH mount and fungal culture were negative.
Figure 1: Nail dystrophy in one hand

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Figure 2: Toenail dystrophy in one foot

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The Budapest criteria is the current standard for diagnosis for CRPS[2] [Table 1] However, diagnosis remains purely clinical without a gold-standard investigation. Our patient fulfilled the requisites of the Budapest criteria.
Table 1: Budapest criteria for chronic regional pain syndrome, 2003

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Cutaneous and nail changes are commonly associated but non-specific to CRPS; thus, they are frequently overlooked. There are three stages of progression of CRPS, but all stages may not occur [Table 2]. It can occur in the setting of underlying conditions such as trauma, infections, ischemic injuries, arthritis, immobilisation, nail surgeries and hemiplegia.[3]
Table 2: Stages of progression for chronic reflex sympathetic dystrophy

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Cutaneous manifestations such as erythema and oedema arising due to vascular components are prominent in CRPS, while papular lesions, folliculitis, skin atrophy, ulcers and bullae are rare. Localised nail dystrophy and non-specific nail changes have been reported with RSD with obscure pathophysiology. Neurological dysregulation and altered microvascular changes have been proposed. An increase in growth and transverse curvature of the nail plate is seen in the first stage, while the second and third stages show progressive brittleness of nails. In our case, there was a prominent and unusual nail involvement with minimal skin involvement.[4],[5]

Trachonychia in RSD is due to disrupted nail matrix differentiation and maturation resulting in the disordered arrangement of keratinocytes leading to nail thinning and brittleness. Beau's lines result from sympathetic denervation and matriceal oedema.[6] Our patient reported painful swelling of nail folds which improved with OTC medications. Over-curvature of the nail plate was seen in our case on the affected great toe along with nail dystrophy, which has been infrequently described. Onychomadesis and pyogenic granuloma due to post-operative immobilisation have been reported.[7] The case highlights unique nail changes in CRPS, exemplifying the fact that manifestations of this diverse condition can be extremely versatile.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Urits I, Shen AH, Jones MR, Viswanath O, Kaye AD. Complex regional pain syndrome, current concepts and treatment options. Curr Pain Headache Rep 2018;22:10.  Back to cited text no. 1
Harden NR, Bruehl S, Perez RSGM, Birklein F, Marinus J, Maihofner C, et al. Validation of proposed diagnostic criteria (the “Budapest Criteria”) for complex regional pain syndrome. Pain 2010;150:268-74.  Back to cited text no. 2
Phelps GR, Wilentz S. Reflex sympathetic dystrophy. Int J Dermatol 2000;39:481-6.  Back to cited text no. 3
O'Toole EA, Gormally S, Drumm B, Monaghan H, Watson R. Unilateral beau's lines in childhood reflex sympathetic dystrophy. Pediatr Dermatol 1995;12:245-7.  Back to cited text no. 4
Tosti A, Baran R, Peluso AM, Fanti PA, Liguori R. Reflex sympathetic dystrophy with prominent involvement of the nail apparatus. J Am Acad Dermatol 1993;29:865-8.  Back to cited text no. 5
Vanhooteghem O, André J, Halkin V, Song M. Leuconychia in reflex sympathetic dystrophy: A chance association? Br J Dermatol 1998;139:355-6.  Back to cited text no. 6
Pampín A, Sanz-Robles H, Feltes RA, López-Estebaranz JL. Onychomadesis and pyogenic granulomas after postoperative upper-limb immobilization. Actas Dermosifiliogr 2014;105:528-9.  Back to cited text no. 7


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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