Counting on fingers and toes

At first glance these nails could either be the most extensive fungal nail infection ever seen, or serious nail psoriasis, but in fact they are examples of the condition known as twenty nail dystrophy. This is usually seen in children and was thought to be a manifestation of lichen planus, but is also associated with alopecia areata, psoriasis, atopy and other inflammatory skin diseases. It is important to do a full skin examination looking for these underlying conditions. It is also a good idea to scrape for fungal culture as well. Most idiopathic childhood cases spontaneously resolve by 20 years of age.