Subungual Melanoma vs. Hematoma

Presented by David Elpern MD,

Williamstown, MA, USA,

June 16th, 2001

History:
This 47 year-old woman has had an asymptomatic, slowly enlarging area of hyperpigmentaton under the left great toenail for 8-10 months

Examination:
There is a tan to grayish 8 mm in diameter pigmentation under the left great toenail. Hutchinson's Sign is negative.

               

Diagnosis:
The patient was seen by two dermatologists and a podiatrist who were concerned about the possibility of melanoma. The negative Hutchinson's sign convinced one of the dermatologists to seek an electronic consultation.

Dr. Elpern contacted fellow VGR-D faculty member Dr. Hiroko Arai of Tokyo for a second opinion about the patient. In turn, Dr. Arai contacted her colleague, Dr. Eckhart Hanecke of Olso, who thought this was most likely a subungual hematoma secondary to microhemorrhage. Dr. Hanecke suggested the following approach:

1. Soak the nail in warm water for ten to fifteen minutes.

2. When the nail is softened, carefully drive a 3 mm punch biopsy through the nail plate. Do not use local anesthesia since one wants the patient to feel when the punch comes close to the nail bed, and therefore, prevent unintentional trauma.

3. Take the 3 mm trepanned sectioned of nail and scrape the bottom. Place the scrapings on a glass slide and add a drop of water. Mix. Then rub a hemocult stick in the mixture. If blood is present it will change color.

The procedure was relatively easy. The nail was a bit tougher than I expected but a specimen was obtained (it came out in the barrel of the punch) and the scraping was delicate. The specimen was held in a hemostat and scraped with a # 15 blade. The nail bed appeared to be of normal pigmentation suggestion that the color was on the nail rather than in the skin.
After a few seconds the strip turned dark green indicating that this was an old subungual hematoma; and we were all relieved. Big smiles on the faces of the patient, her physician husband and me. We were all thankful to Drs. Arai and Haneke for sparing the patient an unnecessary biopsy of the nail bed.

Discussion:
The procedure was atraumatic, with no pain and no bleeding. The nail base was not traumatized. Cases like this are only infrequently encountered by the general dermatologist; and the busy practitioner will often err on the side of caution and perform a biopsy rather than risk missing a dangerous malignancy. However, more experienced experts in nail disorders often have tricks up their sleeves. Virtual Grand Rounds in Dermatology led us to Dr. Haneke who wrote:
"this is a typical example of a subungual hematoma of the big toenail, most characteristically appearing after repeated microtrauma which goes unnoticed by the patient. The lighting of the lesion at its medial margin is also classical as is the lack of involvement of the free nail margin and the
intact hyponychium. For diagnosis, a small punch may be taken from the nail plate only. After a 10-min warm footbath, the nail will be softened and a punch may be run through the nail plate without hitting the nail bed. The pigment can be scraped out and kept in a test tube with a drop of water to dissolve/suspend
it for a Hemostix test. No further surgery is necessary." In a subsequent communication, Dr. Haneke told us to avoid local anesthesia to lesson the chance of driving the punch into the nail bed creating bleeding.

This case demonstrates the utility of VGR-D. It allows dermatologists to consult electronically with more experienced colleagues and the result is improved patient care. As physicians, we are primarily driven by the desire to be of service. Our professions entail practice, learning and teaching. Chaucer wrote, "And gladly wolde he lerne and gladly teche." VGR-D is developing an electronic faculty of experts who gladly share their hard-won knowledge with fellow dermatologists. The rewards are obvious: a grateful and relieved patient, a wiser general dermatologist, and an internationally known professor who has the satisfaction of knowing that his expertise has been of service to others.

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