in india , 23.9 lakh people were living with hiv / aids ( plha ) in 2009 and children under 15 years accounted for 3.5% of all infections . according to who / unaids estimates , 450,000 children were receiving antiretroviral therapy ( art ) and more than 2 million children still needed art in 2010 . zidovudine ( azt ) , being an important component of standard regimen for first - line art in children , is widely used for managing pediatric hiv . as more and more children are exposed to this drug , the range of adverse reactions can also be expected to expand . nail pigmentation with azt is a well - documented occurrence in adults , especially dark - skinned individuals . , we report a case of zidovudine - induced nail pigmentation in a 12-year - old boy . in december 2011 , a 12-year - old boy was brought by guardians to dermatology opd for nail pigmentation involving all fingernails . about 4 years back , art was started for him with stavudine - based regimen ( 12 mg stavudine + 60 lamivudine + 100 mg nevirapine ) because of too low hemoglobin level . but after improvement in hemoglobin level , he has been shifted to zidovudine - based regimen ( zidovudine 300 mg + lamivudine 150 mg + nevirapine 200 mg ) since last 1 year . after 3 months of initiating the new regimen , he noticed bluish - brown discoloration of thumbnails that gradually spread to other fingernails [ figure 1a and b ] and grew in intensity over time [ figure 1c and d ] . there was no history of trauma , use of coloring agents , any triggering factor , or abnormal skin or mucosal pigmentation . ( a ) pigmentation involving all nails ( december 2011 ) ; ( b ) thumbnail involvement ( december 2011 ) ; ( c ) increased pigmentation in all nails ( march 2012 ) ; ( d ) increased pigmentation in thumbnails ( march 2012 ) on examination , he was averagely built , nourished , and fully immunized . local examination revealed diffuse bluish - brown discoloration of all fingernails , but it was more marked in thumbnails . nails were brittle with loss of lunulae and periungual changes [ figure 1c and d ] . the patient and guardians were counseled about harmless nature of this adverse drug reaction ( adr ) and he is receiving the same regimen at present . nail pigmentation with zidovudine was first described by furth and kazakis in two black patients in whom progressive hyperpigmentation of all fingernails developed . since then , several such case reports have been published from various parts of the world.[68 ] but all these patients were adults , and we did not come across any case report on pediatric patients . though our patient was receiving three antiretroviral drugs , zidovudine was thought to be the most likely cause of nail pigmentation , as pigmentation developed after 3 months of initiating zidovudine - based regimen . the causality assessment by naranjo algorithm showed that this adr was  probable  with zidovudine . in previous studies , patients taking zidovudine had noticed nail changes in 48 weeks or even after 56 months.[1011 ] dark - skinned individuals are at higher risk of this adverse effect and it appears to be reversible and dose dependant . nail pigmentation occurs in variety of medical conditions and is also associated with use of several drugs , especially chemotherapeutic agents . the pattern of nail pigmentation may be transverse bands , longitudinal bands , or diffuse discoloration . histopathologic findings of nail biopsy show deposits of brown pigmented granules containing melanin throughout the epidermis . as more patients receive zidovudine , it is important to alert patients about nail pigmentation . though it is harmless and reversible , psychological aspects of this noticeable side effect may hamper adherence and efficacy of therapy . this may also lead to unnecessary investigations and treatment for misdiagnosis such as cyanosis and melanoma . physicians should also focus on preventing adverse effects and distinguishing serious adrs from self - limiting adrs in order to manage prejudiced and fearful patients with available art .
zidovudine is an important component of first - line antiretroviral treatment ( art ) regimens used to manage pediatric hiv . 
 nail pigmentation with zidovudine is a well - documented occurrence in adults , especially dark - skinned individuals . 
 but it has so far not been reported in children . here , we report a pediatric case of zidovudine - induced nail pigmentation . a 12-year - old boy receiving art with zidovudine , lamivudine , and nevirapine presented to dermatology opd with complaint of diffuse bluish - brown discoloration of all fingernails . 
 the pigmentation was noticed by the patient after 3 months of initiating zidovudine - based regimen . 
 it first appeared in thumb nails , gradually involved all fingernails , and increased in intensity over time . 
 though harmless and reversible , psychological aspects of this noticeable side effect may hamper adherence to therapy and may lead to unnecessary investigations and treatment for misdiagnosis such as cyanosis or melanoma .