Twenty-Nail Dystrophy and Darier's (Darier-White) Disease.

A 35-year-old married man presented with progressive distortion of all the nails of the hands and toes for the past 30 years. Initially, his parents noticed yellowish discoloration and roughness of the thumb nail at the age of 5 years. Since then, the changes have been insidious to involve the other nails. Currently, the nails are lusterless, rough, ridged, and difficult to trim. In addition, the patient has had dark, dirty-looking raised eruptions over the skin, attended by generalized itching, corresponding to the onset of the nail lesions. His mother experienced similar disease. Examination of the nails was marked by alternating elevation and depression (ridging) and/or pitting, lack of luster, roughening, sandpaper texture, and splitting, along with muddy, grayish white discoloration. Dystrophy of the nails was prominent. The changes were bilateral and symmetrical, affecting all 10 fingers and 10 toes (Figure 1).