This pigmentary change usually occurs as longitudinal melanonychia (LM) because of melanin deposition in the nail plate. In most cases, melanonychia striata is a benign condition, especially in children. The session came after a recent nationwide survey performed by Of 142 dermatology residents, as well as 58 junior and 199 senior attending dermatologists, just 18.2% performed nail exams at each visit, and most (58%) only looked at nails during the total body skin exam. Over half (62%) of resident physicians reported feeling not confident about melanonychia diagnosis and management, while that figure dropped to 8.6% for senior attending physicians.
“Contact dermoscopy is helpful, so I always have ultrasound gel available,” Dr. Lipner said. The pathologist did.” “Dermoscopy is very helpful” for subungual hematomas, which will usually show a homogeneous pattern, although “you can also see peripheral fadings, streaks, and periungual hemorrhages,” she added.It is important to monitor these patients “because melanomas can bleed,” she said. Melanonychia is a challenging topic in dermatology, in which new knowledge is constantly being added to the clinical, dermoscopic, and surgical practice.. “The source of pigmentation is in the nail matrix, so the biopsy specimen must be taken from there,” Dr. Scher said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery. “If the pathologist sends you back a report that there’s no pigment here, the implication is that you missed the lesion. But if you have nail plate there, which has pigment in it, you didn’t miss the lesion. So if you see lack of uniformity, think of things like atypical nevi, dysplastic nevi, or melanoma.” Nail plate pigmentation (melanonychia) is a rather common clinical occurrence. Consequently, most investigators advocate a wait‐and‐see approach. “We need reliable clinical criteria to determine melanoma probability, but we don’t have it yet. “That’s a number that keeps me awake at night.”
A wide variety of common and less-common culprits may crop up, including from tar, tobacco, henna and other hair dyes, potassium permanganate, and even newspaper print, she said. Nilton Di Chiacchio MD, PhD, Leandro F. Noriega MD, in Nail Disorders, 2019. Dermoscopy will show irregular fading of the discoloration toward the medial aspect of the nail, and gram staining of affected clippings will show gram-negative rods.Shari Lipner, MD, outlined a rational approach for evaluation of longitudinal melanonychias during a nail disorder–focused session Tomizawa K(1). The pathology report read (in part): “atypical junctional melanocytic proliferation with increased numbers of single melanocytes ...; although this lesion is most probably a nevus, it is recommended that it be completely but conservatively excised.” However, alarming clinical and dermoscopic features can be observed, requiring nail surgery to confirm a diagnosis. In cases of subungual melanoma, the patient may describe a long-standing history of longitudinal melanonychia that recently changed in appearance. It’s important to be able to see all nails, she said, but she and her collaborators, including first author Pierre Halteh, MD, who was then a medical student at Cornell, discovered from their survey that “few physicians (32/402; 8%) asked their patients to remove nail polish at every visit.”Longitudinal melanonychias can have a nonmelanocytic etiology, which can range from subungual hematomas to pseudomonas and fungal infections to exogenous pigment.Overall, subungual hematomas are the most common cause of melanonychia, although longitudinal hematomas are not commonly seen. The girl’s parents sought the opinion of seven other pathologists and clinicians at a melanoma conference, and all agreed with complete excision. The parents agreed to proceed with a nail biopsy, Dr. Scher said. As per its name, longitudinal melanonychia is recognized by the appearance of a pigmented stripe, either partial or complete, running length-wise along the nail bed. “However, acral melanoma is more common in African Americans, compared with other populations.” Other causes of melanonychia include trauma to the nail, infection, and certain medications including antibiotics and chemotherapeutics agents. Family history revealed a maternal second cousin with acral melanoma. Other useful tools include a double-action nail clipper, which, she said, is a worthwhile investment.Because patients who are concerned about one of their nails will often come to their appointment with nail polish still on the other nails, Dr. Lipner always has polish remover pads available in the office. The entire nail unit was removed during surgery and the lesion healed with “a terrific cosmetic result,” he said. To illustrate his point he discussed the case of a 4-year-old healthy girl who presented to his office with an 8-month history of melanonychia and a 3-month history of possible nail fold pigmentation. SANTA BARBARA, Calif. – The only way to definitively rule out melanoma in a case of melanonychia striata is to perform a biopsy of the nail matrix, according to Dr. Richard K. Scher. Dr. Scher estimated that 90% of melanocytic bands arise from the distal matrix, which contains more melanocytes than the proximal matrix does. Melanonychia secondary to subungual melanoma has the highest morbidity and mortality compared with other body sites, with reported 5- …
“At most, dermoscopy should be an aide,” he commented.
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