Nail Manifestations in COVID-19: Insight into a Systemic Viral Disease

Abstract

Nail manifestations are 1 of the several extrapulmonary findings associated with COVID-19 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Nail changes, however, have been largely ignored and not yet summarized. This article is intended to increase awareness of nail manifestations of SARS-CoV-2, which occur weeks to months after acute infection and the periungual pernio-like changes may occur concomitantly with infection. An electronic search was carried out in PubMed (Medline), Science Direct, and Scopus databases. The following keywords and all of their possible combinations were used to identify studies: "SARS-CoV-2," "COVID-19," "Coronavirus," "2019-ncov," "nail," and "nails." Six case reports were included in this study. Manifestations identified included red half-moon sign, transverse orange nail lesions, Mees' lines, and Beau's lines. Though largely nonspecific, these findings can be recognized with the onset of symptom onset or as late as 16 weeks following the disease. Some of these findings are shared with other conditions associated with a proinflammatory state. Nail changes offer unique insight into the pathophysiologic basis for SARS-CoV-2 and they may serve as diagnostic clues.

Keywords: Beau's lines; Mees' lines; Nails; Periungual pernio-like changes; Red half-moon sign; SARS-CoV-2; Transverse orange nail lesions.

Conflict of interest statement

Robert T. Brodell has participated in multi-center clinical trials with Corevitas (Formerly Corrona) Psoriasis Registry and Novartis. He is also an associate editor of the Journal of the American Academy of Dermatology, Faculty advisor for the American Medical Student Research Journal, and editor-in-chief of Practice Update: Dermatology, and serves as Staff Dermatologist at the GV (Sonny) MONTGOMERY VA HOSPITAL in Jackson, MS. Daniel III C. Ralph is among the board of directors of Council for Nail Disorders, European Nail Society, and St. Dominic Health Services Foundation. He is also Clinical Professor of Dermatology at the University of Alabama at Birmingham. He is also American Dermatological Association Chairman of Endowment Committee. He serves on the editorial board of the Skin Appendages Disorders and on the advisory board of Ortho Pharmaceutical. He is also the co-editor of a book Scher and Daniel's Nails, Fourth edition, Springer, Philadelphia, 2018. He is also a stakeholder of Medimetriks. Ana Preda-Naumescu, Kayla Penney, Ross L. Pearlman, and Vinayak K. Nahar have no conflicts of interest.

Copyright © 2021 by S. Karger AG, Basel.

Figures

Fig. 1

The red half-moon sign. Red, horizontally oriented, convex bands span the distal margin of the lunula 2 days after the onset of SARS-CoV-2 infection. Permission to use this image was granted by the International Journal of Dermatology on April 23, 2021. Fig. 1, page 1414 [6]. SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

Fig. 2

Transverse orange nails. Distal orange discoloration appeared 16 weeks after SARS-CoV-2 infection with a straight border separating this finding from the proximal healthy-appearing nail bed. Permission to use this image was granted by Dermatologic Therapy on April 23, 2021. Fig. 1, page 1 [7]. SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

Fig. 3

Transverse leukonychia (Mees' lines). Transverse, nonblanchable white lines are present on all fingernails that slowly grew out. This photograph was taken 45 days after the lines were first noted during a hospitalization for SARS-CoV-2 infection. Permission to use this image was granted by Dermatologic Therapy on April 23, 2021. Fig. 1, page 5 [9]. SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

Fig. 4

Beau's lines. Horizontal nail grooves were noted on all ten fingernails growing distally with nail growth. This photograph was taken 3 and a half months following a diagnosis of SARS-CoV-2 [10]. Permission to use this image was granted by Canadian Medical Association Journal on April 23, 2021. Fig. 1, page E1040 [10]. SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.