# Atypical Presentation of Pemphigus Vulgaris: Nail Involvement in a 20-Year-Old Male

## TL;DR

A 20-year-old male with pemphigus vulgaris showed rare nail changes, which improved with treatment and highlight the importance of nail symptoms in assessing disease severity.

## Contribution

This case adds to the limited literature on PV-associated nail changes, particularly in younger patients.

## Key findings

- Nail changes in PV correlated with disease severity and improved with treatment.
- The case emphasizes the importance of examining nail symptoms in PV diagnosis and management.
- Increased medication dosages and rituximab led to resolution of lesions and improvement in nail changes.

## Abstract

Pemphigus vulgaris (PV) mainly causes blistering of the skin and mucous membranes, with nail unit involvement being rare. Nail involvement may serve as an indicator of disease severity. We present a case of a 20-year-old male with PV who had both cutaneous and nail findings, with nail changes corresponding with disease severity. The patient with biopsy-confirmed PV, on prednisone and mycophenolate, presented to the emergency department with an acute flare of PV and severe mandibular pain and lymphadenopathy. At follow-up in our outpatient department, the physical examination was significant for onychomadesis and onycholysis of the fingernails. Prednisone and mycophenolate dosages were increased, and rituximab infusions were initiated. Bullae and mucosal lesions resolved on the follow-up, and nail changes improved. This case appends an unusual perspective to the limited literature on PV-associated nail changes, especially in younger patients. It advocates for meticulous history taking and physical examination and supports a correlation between nail symptoms and PV disease severity.