Nail lesions Flashcards by David Whiting

Longitudinal nail pigmentation - AKA ….

melanonychia striata longitudinalis

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melanonychia striata longitudinalis definition

pigmentation along nail plate in band-like fashion

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melanonychia striata longitudinalis is symmetrical because …

pigmentation of nail matrix produced pigmentation along nail plate with band like fashion - the lesion is symmetrical because of growth of the nail plate

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Does symmetrical lesion r/o melanoma

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Importance of early diagnosis on fingers and toes -

Can offer conservative treatment

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melanonychia striata longitudinalis benign causes

ethnic type pigmentation
subungual hemorrhage 
letiginosis - Laugier Hutziker disease
drug induced - AZT + anti-TB drugs
onychomycosis - very rare cause 
trauma induced pigmentation - common 
melanocytic nevus
onychomatricoma

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melanonychia striata longitudinalis malignant causes

SCC in situ - Bowen’s disease

Melanoma

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subungual hemorrhage confusing patterns -

some cases may have band like pattern

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onychomycosis rare pattern

band like pigmentation

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when should fungal infection be considered as cause of pigmentation?

When all other causes excluded

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trauma induced pigmentation - cause -

due to friction 2nd toe over first one

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trauma induced pigmentation - common sites -

external aspect big toe

intimal aspect big toe

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bowen’s disease - relationship of pigmentation to skin type

on skin pigmentation usually observed in dark skin

on nail pigmentation can occur in light skinned individuals

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is Bowen’s disease on nail common?

no, it is very rare.

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onychomatricoma - what is it?

Rare tumour
Specific to nail unit
Dt proliferation of nail matrix.

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onychomatricoma - how does it enter into differential

May produce pigmented band on nail unit

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melanonychia striata longitudinalis - problems with surgery

very painful

will likely disfigure the nail and may lead to functional problems with the digit

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Clinical algorithm for avoiding biopsy

Acquired during childhood
Polydactlylic
Stable
Another good explanation - drug, ethnicity etc

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Clinical algorithm for avoiding biopsy

Acquired during childhood
Polydactlylic
Stable
Another good explanation - drug, ethnicity etc
No periungual inolvement.

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Melanoma of nail is most common melanoma in ….

black people who also have ethnic pigmentation

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Clinical algorithm in favour of biopsy

Acquired during adulthood
Monodactylic
Changes over time - long period of observation
Peri-ungual involvement. (Hutchinson’s sign)
Polychromia
Triangular shaped

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Clinical algorithm in favour of biopsy

Acquired during adulthood
Monodactylic
Changes over time - long period of observation
Peri-ungual involvement. (Hutchinson’s sign)
Polychromia
Triangular shaped (adult)
Changes of plate - erosion/ longitudinal groove

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Triangular shape in adult means …

lesion is enlarging faster than nail is growing

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Hairpin vessels surrounded by white tissue in favour of …

keratinizing tumour in nail unit

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Atypical vessels, linear irregular, milky red areas, multiple types of vessels in favour of ...

suggestive of melanoma

Remnant of pigmentation on Dermoscopy in favour of ...

malignancy, likely melanoma

Blood spots, due to ...

hemorrhage under nail plate

Blood spots, colour

not specific - purple or red, recent | black or brown, older

Blood spot, shape

Proximal rounded | Distal filamentous

Blood spots are observed in ....... % of melanomas of nail unit.

60%

Blood spots are observed in ....... % of SCC of nail unit.

25%

Blood spots - management

ensure lesion resolves over time. 4 + 12 months

Background pigment

Brown - significant melanocytic hyperplasia. | Grey or yellowish - increased contact of melanin in keratinocytes

Melanocytic lesions - colour is largely related to ...

skin type

Brown longitudinal lines - benign

brown background, lines are regular in colour, spacing, and thickness

Brown longitudinal lines - melanoma

irregular colour, spacing, thickness | rarely parallelism disruption

Greyish or grey yellowish background pigment

``` Ungual Lentigo Ethnic pigmentation (darker skin) Laugier Hunziker Drug induced Repetitive trauma (darker skin) ```

Micro-hutchinson's sign. (Rare)

Pigmentation of peri-ungual skin only observed with Dermoscopy.

Micro-hutchinson's sign, significance...

Usually melanoma

Longitudinal whitish/ yellowish pigmentation is known as ...

Longitudinal leuco/xanthonychia.

Longitudinal whitish/ yellowish pigmentation is known as ...

Longitudinal leuco/xanthonychia.

Yellowish pigmentation is significant when ....

associated with distal subungal hyperkeratosis

Yellowish pigmentation is significant when ....

associated with distal subungal hyperkeratosis

Yellowish pigmentation associated with distal subungal hyperkeratosis suggests that ...

there is a keratinizing tumour in nail matrix.

Yellowish pigmentation associated with distal subungal hyperkeratosis may also be associated with ...

erosion of distal nail plate or longitudinal grooves in the nail plate

distal subungal hyperkeratosis is observed by ...

examination of the distal nail unit by Dermoscopy

splinter hemorrhages are common finding in ....

nail unit tumours

Longitudinal leuco/xanthonychia is observed in % SCC

60%

Longitudinal leuco/xanthonychia is observed in % Onychomatricoma

53%

Longitudinal leuco/xanthonychia is observed in which other lesions?

Hemangioma 30% | Glomus cell tumour 30%

subungal distal hyperkeratosis is observed in % SCC

73%

subungal distal hyperkeratosis is observed in % Onychomatricoma

70%

Linear micro-hemorrhages are common in ...

any type of malignant tumour

Linear micro-hemorrhages in tumours manifest as ...

linear hemorrhages in band-like fashion

Linear micro-hemorrhages without pigmentation good sign of ...

keratinizing tumour

Linear micro-hemorrhages occurs in what type of melanoma?

Advanced melanoma

Linear micro-hemorrhages observed in % onychomatricoma

67%

Linear micro-hemorrhages observed in % SCC

35%

Linear micro-hemorrhages observed in % Achromic malignant melanoma

40%

Pigmented melanoma Dermoscopy features: Common

``` Brown background (95%) Irregular pattern of lines (95%) ```

Pigmented melanoma Dermoscopy features: Uncommon

Micro Hutchinson's sign 15% | Splinter hemorrhages 5% (advanced cases)

Nail-matrix melanocytic nevus dermoscopic patterns

Brown background 100% | Regular pattern of lines 94%

Subungual hemorrhage dermoscopic patterns

Blood spot 100% * No other sign * Clearance of lesion 3-6 months

When looking at subungual hemorrhage always ....

use the Dermoscope

Nail unit lentigo and lentiginosis

Grey lines 93% | No other change of nail plate

Grey lines 93%, No other change of nail plate also found in ....

Drug induced pigmentation Chronic trauma inducted pigmentation Ethnic type pigmentation

Pigmented Bowen's disease uncommon Dermoscopy features

Subungual distal hyperkeratosis 70% Longitudinal leuco-xanthonychia 60% Polychromia (grey, white, yellow, red) 45% Triangular distal onycholysis, convex deformity and yellow spot 40% Linear microhemorrhages (35%)

Onychomatricoma

``` Subungual hyperkeratosis (73%) Linear microhemorrhages (67%) Convex deformity of the nail plate, longitudinal leucoxanthonychia (53%) Triangular distal onycholysis ```

Follow u p with doubtful lesions

4,8,12,18 months

Probably with too early surgery -

very early melanoma shows few atypical melanocytes - can confuse pathologist.

Clinical management algorithm

Atypical > Surgical biopsy | Non atypical > 4 month control > no modification> annual follow up.

Dermoscopy nail bed and matrix - non melanocytic

homogenous pigmentation - brown or grey

Dermoscopy nail bed and matrix - melanocytic

bands

Dermoscopy nail bed and matrix - benign patterns

Non melanocytic Lines regular Lines regular + regular globules