a 79-year - old caucasian gentleman presented with a ten year history of fingernail and toenail nail dystrophy and fingernails that  broke off once a year , usually in winter . he had a background history of hypertension and mild dementia and much of the history came from his sons , who helped to take care of him . these episodes of nail shedding were asymptomatic , with no history of preceding illnesses or symptoms . the patient had several haematological and radiological investigations performed to exclude a sinister cause for the nail shedding . there was no contact with chemicals or heavy metals or ingestion of any chemicals , in particular lead or arsenic . there was a family history of type 2 diabetes mellitus and no other dermatological conditions were present . the patient had received the vaxigrip influenza and pneumovax 23 vaccine in may and june 2007 , respectively . other than these two vaccinations , there were no new medications or changes to his medication regime . on examination in 2007 there were beau 's lines of all the fingernails with the distal nail plate intact ( figure 1 ) . there were no other fingernail findings such as discolouration , subungual haemorrhages , hyperkeratosis , onycholysis or signs of paronychia . there was no evidence of dermatological pathology on examination of his skin and mucosal surfaces . during this initial visit , the provisional diagnosis was exposure to toxins resulting in beau 's lines in the fingernails or onychomycosis . toenail clippings were sent for microscopy , fungal culture and periodic acid - shiff ( pas ) examination . routine blood tests included full blood count , urea , electrolyte , creatinine , liver function tests , serum folate and vitamin b12 , iron studies , homocysteine levels and thyroid function . microscopic investigation of the toenail clippings revealed no fungal elements and pas staining was negative . the patient returned for follow up two months later and reported the asymptomatic loss of six of his ten fingernails . the patient subsequently returned for review in august of 2008 and beau 's lines were still present on his finger nails ( figure 3 ) . serum arsenic , lead , cadmium levels and repeat full blood count ( fbc ) , eletrolytes urea and creatinine ( euc ) and liver function tests ( lfts ) were normal . the initial differential of onychomycosis was rejected as toenail fungal culture and pas staining was negative . the provisional diagnosis was that of seasonal nail shedding and the patient was commenced on vitamin d , calcium , zinc and folate supplementation after the first consultation , due to suspicion that he may be deficient even if his blood tests did not reveal any deficiencies . the patient was noted to have beau 's lines and onychomadesis of all fingernails and periodic nail shedding during the winter months over a two - year period . this case highlights an interesting seasonal phenomenon of onychomadesis of predominantly fingernails in an elderly , demented gentleman . in 1846 , beau first described transverse grooves in the nail plates of patients suffering with typhoid fever and several other severe systemic conditions . beau 's lines are transverse ridged grooves found on fingernails and may be secondary to trauma , drugs , such as chemotherapy agents , severe systemic disease , zinc deficiency , carpal tunnel syndrome , dermatitis of the skin directly adjacent to the nail or malnutrition . the transient and complete inhibition of nail growth for at least one to two weeks results in beau 's lines . onychomadesis is characterized by cleavage under the proximal portion of the nail proceeded by disappearance of the juxtamatricial portion of the nail surface . in latent onychomadesis , beau 's lines are apparent on the nail surface and become visible several weeks after the onset of the causative systemic disease . scarring nail loss may be due to tumours or erosive lichen planus or severe systemic disease . onychomadesis may be secondary to a number of causes including severe systemic illnesses , bullous dermatoses such as epidermolysis bullosa , adverse drug reactions , particularly to chemotherapeutic agents , acute paronychia or severe stress . onychomadesis may be inherited in an autosomal dominant form and is associated with periodic shedding , but the majority of cases are idiopathic . in cases of latent onychomadesis , a complete and transient inhibition of nail growth results in beau 's lines . nail shedding associated with kawasaki syndrome , severe alopecia areata , hand - foot and mouth disease , cutaneous t - cell lymphoma , severe psychological stress , intensive x - ray therapy , acute paronychia , pyogenic granuloma , sle , keratosis punctata and bullous dermatoses such as pemphigus have also been reported . in our case no specific cause could be found , but the seasonal nature of his presentation might suggest a viral / infectious aetiology despite the lack of evidence . periodic nail shedding has also been described in patients with and without a family history of epidermolysis bullosa , but this patient did not have a family history of epidermolysis bullosa . this is a case of idiopathic onychomadesis in a gentleman who was diagnosed after ten years that appeared every year in winter , with no apparent cause . many cases of onychomadesis may be overlooked by physicians as they may not be voiced by the patient or may be simply put down to nail shedding secondary to trauma . patients with periodic nail shedding should be thoroughly investigated for severe systemic illnesses , adverse drug reactions and heavy metal toxicity .
a 79-year - old man with a history of dementia and hypertension initially presented with a ten year history of beau 's lines and seasonal nail shedding of his fingernails only . 
 he denied any exposure to heavy metals , unusual activities or food . 
 he stated that the seasonal nail shedding had been occurring for the last 510 years . on examination , 
 six out of ten fingernails had been affected . 
 he had significant toenail dystrophy . 
 fungal cultures and pas staining of the toenails were negative . 
 routine serum biochemistry and haematology results were normal . 
 serum arsenic , cadmium and lead levels were also normal . 
 vitamin b12 , zinc , folate , iron studies , thyroid function studies and homocysteine levels were also normal . 
 rheumatoid factor and anti - cyclic citrullinated peptide antibody antibodies were negative . 
 bilateral hand x - ray showed osteoarthritic change and did not show any features of psoriatic arthropathy . 
 we discuss the case of a 79-year - old man with seasonal nail shedding , curiously affecting his fingernails only .