Twenty nail dystrophy (TND) is a condition is which the texture of the nails change. It is also known as trachyonychia, which translates to “rough nail condition” in Latin. This presents as diffuse roughness and excessive longitudinal ridging usually involving all twenty nails, giving it a sandpaper like appearance. The nails become brittle and thin and the cuticles may become ragged. Occasionally the nails appear shiny due to the numerous tiny punctate depressions that can appear on the nail plate.

TND is often seen at birth and evolves slowly over time. The peak age of the disease is 3-12 years of age. It can present as its own entity or in association with alopecia areata (45-83%), psoriasis (13-26%), or lichen planus (4-18.5%). Although rare, it has been associated with many other diseases.

Due to the ability to diagnose TND clinically, nail biopsies are not recommended as permanent cosmetic damage can occur. However, a biopsy can be done to help reassure highly concerned patients.

Treatment of any underlying cause/association should help resolve the defect of the nail. TND is a self-limiting condition that may clear spontaneously over several months to several years without leaving any residual scarring. Patients should be counseled and reassured that abstinence of therapy is an acceptable and safe option. If there is no associated dermatologic disease, then treatment is often unsatisfactory. Some treatments which may be tried include topical or oral steroids, topical PUVA, biotin, and topical retinoids. Cosmetically, buffing and filing of the nail plate can improve the appearance.

Follow up is necessary as twenty-nail dystrophy can precede alopecia areata, psoriasis, and lichen planus. 

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