Nail abnormalities in upper extremity transplantation: Perspectives and insights from systemic diseases and organ transplantation

Table 1 Comparative summary of nail changes in upper extremity transplantation, solid organ transplantation, and systemic/autoimmune diseases

Nail change	UET	Solid organ transplantation (kidney, liver, HSCT)	Systemic/autoimmune diseases	Ref.
Onychomadesis	Often with acute/chronic rejection; may precede skin changes	MMF-associated; reported after kidney/Liver transplantation	Autoimmune disease (e.g., pemphigus), viral infections (e.g., hand foot and mouth disease)	Schneeberger et al[13], Kanitakis et al[19], Hardin and Haber[35], Rault[42]
Onycholysis	May occur with rejection or chronic vascular compromise	Reported after liver transplantation; MMF-related	Thyroid disease, irondeficiency anemia, allergic contact dermatitis	Schneeberger et al[13], Cabanillas et al[22], Alessandrini et al[43]
Nail dystrophy	Atypical skin/nail rejection pattern in UET	Reported in liver transplant cases	Iron or biotin deficiency	Schneeberger et al[13], Abdelaziz et al[25], Shrimal and Gupte[28], Stefańska et al[33]
Thinning/thickening of nail plate	Seen with chronic rejection and ischemia	-	Psoriasis, systemic sclerosis	Hautz et al[21], Abdelaziz et al[25], Shrimal and Gupte[28]
Lunula changes	Changes reported around rejection episodes	Absent/reduced lunula reported in kidney/Liver recipients	Systemic sclerosis, dermatomyositis	Marinho and Perdigoto[26], Gandhi et al[27], Shrimal and Gupte[28]
Leukonychia	Described in UET recipients	Common in kidney and liver transplant; drugrelated (sirolimus/MMF)	Hypoalbuminemia, malnutrition	Marinho and Perdigoto[26], Gandhi et al[27], Shrimal and Gupte[28]
Onychomycosis	Opportunistic infection under immunosuppression	Common in kidney transplant; immunosuppressantrelated	-	Bodman et al[36], Hay and Baran[37], Mehta et al[38], Piraccini and Alessandrini[39], Zaraa et al[40], Pharaon et al[44], Lee and Lipner[45], Gaurav et al[46]
Beau’s lines	Matrix interruption from ischemia/rejection	Reported in kidney/Liver transplant recipients	Autoimmune/systemic illness, nutritional deficiencies	De Berker[10]
Trachyonychia/Longitudinal ridging	Chronic rejection; microvascular changes	Reported after HSCT	Psoriasis, lichen planus	Kanitakis et al[19], Stefańska et al[33]
Splinter hemorrhages	-	Observed in transplant recipients; drug-related	Endocarditis, vitamin C deficiency, systemic sclerosis	Saladi et al[41]
Clubbing	-	Reported especially in pediatric liver transplantation	Pulmonary and cardiac disease, systemic sclerosis	Abdelaziz et al[25], Shrimal and Gupte[28]

It summarizes the spectrum of nail changes observed in upper extremity transplantation (UET), compared with solid organ transplantation (SOT) and systemic/autoimmune diseases. While certain findings such as onychomadesis and lunula changes may herald graft rejection in UET, others (e.g., leukonychia, clubbing) are more common in SOT or systemic disease contexts. Recognizing these patterns can help differentiate immunemediated rejection from comorbid conditions and treatmentrelated effects. HSCT: Hematopoietic stem cell transplantation; MMF: Mycophenolate mofetil; UET: Upper extremity transplantation.