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

Introduction: Alopecia areata (AA) is an organ-specific autoimmune disorder producing non-scarring alopecia that ranges from isolated patches to total scalp loss (alopecia totalis, AT) or loss of all body hair (alopecia universalis, AU). Although the nail unit may also be affected and is widely regarded as a poor prognostic sign, data on its prevalence and correlates in children with refractory disease remain 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, and ≥1 established poor prognostic factor. Nail morphology, SALT score-based severity, clinical subtype, sex, disease duration, and family history of AA were recorded. Chi-square and Fisher exact tests were applied (p < 0.05). Results: Sixty-three of 91 (69.2%) children had nail involvement. Pitting was the most common finding (47/63; 74.6%), followed by leukonychia (11.1%), trachyonychia (9.5%), longitudinal ridging (3.2%), and Beau’s lines (1.6%). Nail involvement was significantly associated with longer disease duration (p = 0.049) but did not correlate with sex, clinical subtype, or scalp severity (all 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. Routine nail examination provides prognostic insights and may help guide treatment.