Introduction:

Congenital malalignment of the great toenail is characterized by the lateral deviation of the nail plate along the longitudinal axis of the distal phalanx, with subsequent nail thickening and dystrophy. Its pathogenesis remains incompletely understood, and, generally, the lateral deviation of the nail plate is present from birth. This condition is often misdiagnosed and treated as onychomycosis.

Case description:

A healthy 7-year-old girl was referred to a dermatology clinic for “onychomycosis of great toenails”. Prior treatments included topical antifungals for the last 18 months, without any improvement. Physical examination revealed both great toenails to have a tan-yellow discoloration and marked thickening of both nail plates, mild valgus deviation of great toes, and minimal nail changes of second toenails, with no signs of inflammation. These findings were presented almost since birth and there was no history of trauma. Her father had identical symptoms, also resistant to antifungal therapy. The patient was diagnosed with nail dystrophy secondary to congenital malalignment of the great toenails. Due to its mild presentation, topical treatment with urea cream was prescribed, with nail filing according to child comfort.

Comment:

The recognition of this entity ables one to achieve a correct diagnosis, avoiding unnecessary treatments and possible adverse effects. It is important a detailed clinical history, namely the beginning of symptoms and the occurrence of identical symptoms in other family members. Nail changes present since birth or first childhood should alert to a condition different from onychomycosis, which is rare in such young patients.

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