Nail Involvement in Refractory Pediatric Alopecia Areata: A Duration-Dependent Finding

Introduction: Alopecia areata (AA) is an organ-specific autoimmune disorder causing non-scarring alopecia, ranging from isolated patches to total scalp or body hair loss. Nail unit may also be affected and is seen as a poor prognostic sign, data on its prevalence and correlates in children with refractory disease are limited. Methods: We reviewed the records of 91 children (aged 3.5–14 years) with treatment-resistant AA, defined as disease duration ≥6 months, <10% improvement in Severity of Alopecia Tool (SALT) score after ≥2 adequate courses of conventional treatment with poor prognostic factors. The morphology of nails, gender, severity of AA, family history, and duration were recorded. Results: Sixty-three of 91 children (69.2%) had nail involvement. Pitting was the most common finding (74.6%). Nail involvement was significantly associated with longer disease duration (p=0.049) but did not correlate with disease severity (p>0.05). Children without a family history of AA had significantly more severe disease and a higher proportion of AT or AU (p<0.05). Conclusion: Nail involvement was present in nearly 70% of children with treatment-resistant AA, far above rates reported in unselected cohorts. Association with disease duration but not scalp severity suggests that nail-matrix autoimmune activity may follow a partially independent course.