Nail changes as clinical markers of disease spectrum and reactional states in Hansen’s disease: A retrospective record-based cross-sectional study

Background: Nails are an integral component of the integumentary system and serve as a useful window to systemic and dermatological diseases. Hansen’s disease is a chronic infectious condition caused by Mycobacterium leprae , primarily affecting the skin and peripheral nerves. Nail changes in leprosy result from a combination of peripheral neuropathy, repeated micro-trauma, vascular compromise, secondary infections and immunological reactional states. Despite their clinical relevance, nail changes are frequently overlooked, and real-world Indian data on nail involvement in Hansen’s disease remain limited. Objectives: The objectives of the study were to determine the frequency and spectrum of nail changes in Hansen’s disease and to assess their association with various types of leprosy as per the Ridley–Jopling spectrum, or with lepra reactions. Material and Methods: A retrospective, record-based cross-sectional study was conducted over 14 months (November 2020–January 2022) in a tertiary care hospital in Eastern India. Clinical records of 106 patients with Hansen’s disease were analysed. Nail findings were documented and categorised. Data were analysed using descriptive statistics, and associations were tested using Chi-square or Fisher’s exact test, as applicable with a p < 0.05 being considered statistically significant. Results: The mean age of patients was 36.4 ± 15.2 years. Nail changes were observed in 93.4% of cases. Of the 106 patients, 49 (56.6%) belonged to the tuberculoid pole, 11 patients had pure neuritic hansen and 46 (43.4%) belonged to the lepromatous pole. Tuberculoid disease predominantly showed brittle and infective nail changes such as onychorrhexis, onychomycosis and paronychia, whereas lepromatous disease demonstrated advanced dystrophic changes including subungual hyperkeratosis, onychomadesis, brachyonychia, anonychia and trachyonychia. Trachyonychia ( p = 0.033) and subungual hyperkeratosis (p=0.031) were found to be significantly associated with the lepromatous spectrum. Longitudinal ridging, Beau’s lines and onychomadesis were significantly more common in patients with lepra reactions ( p < 0.05); onychomadesis was strongly associated with type 2 reactions. Conclusion: Nail involvement was very common in our cohort and appeared to reflect the disease spectrum, duration and immunological activity. Routine nail examination is a simple, non-invasive assessment that may provide useful clinical clues and can be incorporated into the standard evaluation of patients with Hansen’s disease.