10.5826/dpc.1401a2
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2160-9381
3663
en
Iria Neri
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
onychoscopy
Spotted Lunula in Alopecia Areata: Clinical and Onychoscopic Features of an Unusual Sign 
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Letter to the Editor
2024-01-31
2023-07-07
2024-01-31
2024-02-21
e2024002
Dermatol Pract Concept
Iria Neri
2024/01/31
10.5826/dpc.1401a2
e2024002
Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi; Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy
2160-9381
onychoscopy
en
e2024002
Roest YBM, Van Middendorp H, Evers AWM, Van De Kerkhof PCM, Pasch MC. Nail involvement in alopecia areata: A questionnaire-based survey on clinical signs, impact on quality of life and review of the literature. Acta Derm Venereol. 2018;98(2):212–7.
Spotted Lunula in Alopecia Areata: Clinical and Onychoscopic Features of an Unusual Sign 
https://dpcj.org/index.php/dpc/article/download/3663/2536
         Spotted Lunula in Alopecia Areata: Clinical
       and Onychoscopic Features of an Unusual Sign
    Michela Starace1,2 , Stephano Cedirian1,2, Carlotta Gurioli1,2, Marco Adriano Chessa1,2,
                              Bianca Maria Piraccini1,2, Iria Neri1,2


1 Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
2 Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy



Citation: Starace M, Cedirian S, Gurioli C, Chessa MA, Piraccini BM, Neri I. Spotted Lunula in Alopecia Areata: Clinical and
Onychoscopic Features of an Unusual Sign. Dermatol Pract Concept. 2024;14(1):e2024002. DOI: https://doi.org/10.5826/dpc.1401a2
Accepted: July 23, 2023; Published: January 2024
Copyright: ©2024 Starace et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Bianca Maria Piraccini MD, PhD, Via. G. Massarenti, 9 – 40138 – Bologna (Italy). Tel: +39 0512143848
E-mail: biancamaria.piraccini@unibo.it




Dear Editor,                                                             to matrix inflammation [1,2]. It is more commonly observed
                                                                         in severe forms of AA, such as AA Totalis or AA Universalis,
    Alopecia areata (AA) is an autoimmune disorder char-                 as well as in children [4].
acterized by non-scarring alopecia that can affect any hair-­                 SL was initially described by Shelley in 1980 [5]. A to-
bearing area, although the scalp is the most common site. AA             tal reddish involvement of the lunula, due to arteriolar vas-
can also involve the nail apparatus. The most frequent nail              cularization, has also been reported [6]. Notably, SL is not
manifestation associated with AA are nail pitting and trachy-            commonly referenced in major dermatology textbooks [7],
onychia; however, other signs can also aid in its diagnosis,             and in large population studies, such as the one published
such as punctate leukonychia or Beau lines [1,2]. In this ar-            by Sharma et al with 1000 patients [8]. To the best of our
ticle, we would like to highlight another non-diagnostic but             knowledge, SL has only been reported in two studies: Tosti et
characteristic nail sign of AA, the spotted lunula (SL).                 al documented this finding in a series of 126 pediatric cases,
    SL is a sign that, upon clinical examination, presents as            reporting 6 affected patients, and Roest et a. reported a prev-
small, circular, reddish areas that do not disappear under vit-          alence of 13% in a case-control study [9,10].
ropressure. Its borders are well-defined and regularly distrib-               Regarding prognosis and treatment, spontaneous remis-
uted throughout the lunula. On onychoscopy, dilation and                 sion is often observed in patients with AA, typically with
tortuosity of the distal matrix vessels can be observed, re-             hair regrowth. In cases of isolated nail involvement, some
flecting an involvement of the papillary dermis (Figure 1). SL           patients may require treatment, which is mainly based on
is a sign of nail matrix inflammation associated with various            personal clinical experience and small case series. Topical
diseases, including AA and nail psoriasis [3].                           therapy with corticosteroids, such as mometasone 0.1%
    Nail involvement in AA is not uncommon, although it is               ointment or clobetasol 8% nail lacquer, is the first choice.
not pathognomonic, and according to the literature, it can               For resistant forms, the same systemic treatment regimens
affect anywhere from 7% to 66% of patients, especially due               used for scalp involvement can be considered [1].



Letter to the Editor | Dermatol Pract Concept. 2024;14(1):e2024002                                                                    1
                                                                        2. Starace M, Alessandrini A, Bruni F, Piraccini BM. Trachyonychia:
                                                                           a retrospective study of 122 patients in a period of 30 years.
                                                                           JEur Acad Dermatol Venereol. 2020;34(4):880–884. St DOI:
                                                                           10.1111/jdv.16186. PMID: 31923322.
                                                                        3. Baran R. Comment reconnaître et traiter un psoriasis unguéal
                                                                           [How to diagnose and treat psoriasis of the nails]. Presse Med.
                                                                           2014;43(11):1251-1259. DOI: 10.1016/j.lpm.2014.06.011.
                                                                           PMID: 25443636.
                                                                        4. Kasumagic-Halilovic E, Prohic A. Nail changes in alopecia
                                                                           areata: frequency and clinical presentation. J Eur Acad Der-
                                                                           matol Venereol. 2009;23(2):240-241. DOI: 10.1111/j.1468-
                                                                           3083.2008.02830.x. PMID: 18540984.
                                                                        5. Shelley WB. The spotted lunula: A neglected nail sign associated
                                                                           with alopecia areata. J Am Acad Dermatol. 1980;2(5):385-387.
                                                                           DOI: 10.1016/s0190-9622(80)80360-4. PMID: 7381066.
                                                                        6. Morrissey KA, Rubin AI. Histopathology of the red lunula:
                                                                           New histologic features and clinical correlations of a rare type
                                                                           of erythronychia. J Cutan Pathol. 2013;40(11):972–975. DOI:
                                                                           10.1111/cup.12218. PMID: 24102674.
                                                                        7. Sperling L, Sinclair R, Shabrawi-Caelen L. Alopecias. In:
                                                                           Bolognia J, Lorizzo J, Schaffer J, editors. Dermatology. 4ed.
                                                                           ­
Figure 1. (A,B) Clinical (A) and onychoscopic (B) image of the             ­Elsevier; 2018:1093–1114.
­spotted lunula that appears as a small, circular, reddish area with    8. Sharma VK, Dawn G, Muralidhar S, Kumar B. Nail changes
 visible dilation and tortuosity of the distal matrix vessels.              in 1000 Indian patients with alopecia areata. J Eur Acad Der-
                                                                           matol Venereol. 1998;10(2):189–190. SDOI: 10.1111/j.1468-
    In conclusion, SL is an underappreciated finding in                    3083.1998.tb00727.x. PMID: 9553924.
suspected AA without obvious manifestations, and ony-                   9. Tosti A, Morelli R, Bardazzi F, Peluso AM. Prevalence of Nail
                                                                           Abnormalities in Children With Alopecia Areata. Pediatr Der-
choscopy once again proves to be a crucial non-invasive di-
                                                                           matol. 1994;11(2):112–115. DOI: 10.1111/j.1525-1470.1994
agnostic tool.
                                                                           .tb00562.x. PMID: 8041648.
                                                                       10. Roest YBM, Van Middendorp H, Evers AWM, Van De ­Kerkhof
References                                                                 PCM, Pasch MC. Nail involvement in alopecia areata: A
                                                                           questionnaire-based survey on clinical signs, impact on qual-
 1. Chelidze K, Lipner SR. Nail changes in alopecia areata: an up-         ity of life and review of the literature. Acta Derm Venereol.
    date and review. Int J Dermatol. 2018;57(7):776–783. DOI:              2018;98(2):212–217. DOI: 10.2340/00015555-2810. PMID:
    10.1111/ijd.13866. PMID: 29318582.                                     28967977.




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