Nail Dystrophy Treated With Marigold Therapy in a Patient With Epidermolysis Bullosa Simplex

Epidermolysis bullosa simplex (EBS), the most common subtype of EB, is characterised by intraepidermal mucocutaneous blistering in response to mechanical trauma, most frequently caused by dominant mutations in the keratin 5 (KRT5) or keratin 14 (KRT14) genes [1]. Marigold therapy has a significant history in topical skin therapy for the lower extremities and is available as a paste, tincture, oil, ointment or cream [2]. In particular, the safety, keratolytic and anti-inflammatory properties of the Tagetes species are supported by double-blind, placebo-controlled trials in hyperkeratotic plantar lesions, hallux valgus and verruca pedis (p < 0.001) [2]. We report a case of an EBS patient whose nail dystrophy was treated with Tagetes-based marigold therapy. A 44-year-old female with genetically confirmed EBS (heterozygous likely pathogenic KRT14 variant c.1163G>A; p.Arg388His) presented with chronic blistering localised to the feet since adolescence, triggered by prolonged walking, heat and tight footwear. Examination revealed no active blisters, but minor residual damage from previous blisters. Management included 15% aluminium chloride anti-perspirant spray nocte to the soles to reduce sweating, sterile silicone adhesive wound dressings to reduce friction and trauma, and antimicrobial foam dressings and polymeric membrane dressings to manage active blisters, resulting in satisfactory blister control. Subsequently, she developed an infection of the left hallux following the rupture of a periungual blister, which resolved after three courses of oral cephalexin, though residual frosty-white nail discolouration and surface irregularity persisted. Podiatry assessment revealed nail dystrophy of the left hallux toenail (Figure 1A). Initial treatment included keratolytic Tagetes-based marigold paste to the left hallux toenail and compressible felt pad coverage for 1 week. The patient then self-applied topical marigold tincture and oil twice daily, and wore gel toe protectors. By day seven, the nail surface appeared smoother and clearer, with visible new nail growth at the base of the nail bed (Figure 1B). By 12 weeks, 70% of the nail had grown out and by six months the dystrophic nail had resolved completely (Figure 1C,D). No pain or adverse effects were associated with the treatment. Case reports exist on the use of marigold therapy in median canaliform nail dystrophy affecting both hallux toenails and in lichen striatus nail dystrophy of the right hallux toenail, with resolution achieved within 4 months and 3 months, respectively [3, 4]. Both cases used a similar regimen of a week-long Tagetes paste and an overlying pad, followed by self-application of a tincture and oil, without adverse effects. Similarly, we report the successful use of Tagetes-based marigold therapy in an EBS patient with nail dystrophy. This is likely due to the antikeratolytic, antiviral, antibacterial and antifungal flavonoids (quercetagetin, quercetagetrin, kaempferol and kaempferitrin) contained in Tagetes, facilitating gradual reduction in excess nail keratin [3]. General measures may also have contributed to the improvement of the nail dystrophy, including appropriate foot care and toe protection. Of note, Tagetes belongs to the Compositae (Asteraceae) family, which carries recognised allergenic potential; cross-reactivity with other Compositae plants, including Arnica, should be considered [5]. To conclude, this case illustrates that Tagetes-based marigold therapy may support the restoration of nail architecture in patients with EBS and underscores the need for larger studies to confirm its safety and effectiveness. The authors have nothing to report. The authors have nothing to report. AI statement: AI was not used at any stage of this manuscript preparation. Author Statement: The manuscript is original research and has not been published or under consideration elsewhere. All the authors participated inthe preparation of the manuscript and had a role in writing it. There are no figures or tables printed elsewhere. All patient information contained in this research letter was fully de-identified. Informed consent was obtained from the patient for publication of clinical details and accompanying de-identified images. M.T.K. is Trustee of the Marigold trust and Hon. Clinical Director of research and education. A.S. and D.F.M. declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.