Case Report: What's Your Diagnosis?

Author: Vivian Wong MD-PhD, Department of Dermatology, Warren Alpert Medical School of Brown University; Providence, Rhode Island

Case history:

A 34-year-old female (Fitzpatrick Skin Phototype V) presents with 8-month history of nail discoloration on her right thumb. On examination, there is a 4.3 mm brown patch composed of irregular brownish to grayish longitudinal lines of various widths on the medial nail plate. The lesion does not disappear with pressure. The other finger and toe nails are uninvolved. She denies any preceding trauma and does not take any medication. What is your diagnosis?

Subungual hematoma
Subungual melanoma
Physiologic pigmentation
Pigmented onychomycosis

Answer:

Subungual melanoma

Explanation:

Subungual melanoma is a type of melanoma involving the nail apparatus. It has a predilection for patients with darker skin phototypes. Subungual melanoma is a diagnostic challenge, as numerous conditions could present with nail pigmentation. Several common culprits are discussed here. In addition, dermatologists should always obtain a thorough history to rule out exogenous or medication-induced melanonychia. Therefore, the diagnosis is often delayed, resulting in significant mortality. Further, amelanotic subungual melanoma has been reported, and it could mimick other neoplastic or inflammatory processes, such as squamous cell carcinoma, pyogenic granuloma, and viral warts.

As in this case, subungual melanoma favors a single digit, most likely the thumb of an adult. Examination of the lesion using dermoscopy is often helpful. Signs suggestive of the diagnosis include irregular pigmentation, broad pigment band (at least 3mm), tapered band with a wider base at the origin of the nail plate, blurry and fuzzy borders, and variegated color. Hutchinson’s sign, with pigmentation of periungual tissue, is a classic finding. Laugier-Hunziker syndrome, a benign hereditary pigmentary condition, could present with benign nail pigmentation. Perform serial photography for monitoring if suspicion is low, and perform a nail biopsy if suspicion is high.

Differential diagnoses:

- Subungual hematoma refers to a collection of blood within the nail plate or nail bed, often secondary to trauma. It could resemble subungual melanoma, with red-brown to brown-black discoloration. It typically migrates distally and spontaneously resolves with time, unlike subungual melanoma.

- Physiologic (functional pigmentation) is typically seen in patients of darker skin phototypes. A clue to diagnosis is the involvement of multiple nails. Look for regular longitudinal and rectangular pigment bands with homogenous color.

- Pigmented onychomycosis (fungal melanonychia) occurs secondary to dematiaceous fungal or rarely yeast and mold infections of the nails. Look for subungual debris, nail thickening, yellowish discoloration and onycholysis, in addition to brown-black discoloration. Multiple nails, typically the toe nails, are involved. Looks for evidence of concomitant tinea pedis, which presents with scaly plaques on the soles, lateral aspects of the feet and the interdigital spaces.

References:

Mun, J.-H., Kim, G.-W., Jwa, S.-W., Song, M., Kim, H.-S., Ko, H.-C., Kim, B.-S. and Kim, M.-B. (2013), Dermoscopy of subungual haemorrhage: its usefulness in differential diagnosis from nail-unit melanoma. British Journal of Dermatology, 168: 1224–1229.

Braun RP, Baran R, Le Gal FA, Dalle S, Ronger S, Pandolfi R, et al. Diagnosis and management of nail pigmentations. J Am Acad Dermatol. 2007;56:835–847.

Dominguez-Cherit, J., R. Roldan-Marin, P. Pichardo-Velazquez, C. Valente, V. Fonte-Avalos, M. E. Vega-Memije, and S. Toussaint-Caire. "Melanonychia, Melanocytic Hyperplasia, and Nail Melanoma in a Hispanic Population." [In Eng]. J Am Acad Dermatol 59, no. 5 (Nov 2008): 785-91.

Wong V, Burgin S, Richert B, Baran R. “Subungual melanoma (nail melanoma)”. In: Goldsmith LA, editor. VisualDx. Rochester, NY: Logical Images. https://www.visualdx.com/visualdx/diagnosis/subungual-melanoma?moduleId=19&diagnosisId=56099

Wong V, Burgin S, Richert B, Baran R. “Onychopapilloma”. In: Goldsmith LA, editor. VisualDx. Rochester, NY: Logical Images. https://www.visualdx.com/visualdx/diagnosis/onychopapilloma?moduleId=19&diagnosisId=56100

Find out what you can learn from Wendy Lewis of @BeautyintheBag, as she met with SOCS Physicians at Media Day in New York.

Check out her full article here.

By 2050, more than 50 percent of the US population will have skin of color. As it stands, skin of color patients are the majority in California, New Mexico, and Texas, and soon will be the majority in Arizona, Nevada, Georgia, New York, and Florida, the Skin of Color Society reports.

Visit Practical Dermatology's website for full article.

2016 Skin of Color Society Media Day

Delving into Diversity

A deeper look into the latest dermatologic issues, trends and breakthroughs with leading skin of color experts

Join us for Luncheon Presentations and Roundtable Discussions with the Skin of Color Society Experts

Tuesday, December 13, 2016 The London Hotel, NYC, Regent Park Room 151 West 54th Street New York, NY 10019 12:00 noon -2:00 pm

Private appointments with the Skin of Color Society Experts are also available before and after the Luncheon program.

Skin of Color Society Presentation topics and experts:

Team 1: Skin of Color Health+Beauty Tech Talk - Get the scoop on the hottest derm-related technological breakthroughs, newer treatments, lasers, at-home gadgets, apps, trends, etc., with special emphasis on risks/concerns in skin of color, led by: Dr. Nada Elbuluk and Dr. Babar Rao.

Nada Elbuluk, MD, MSc, FAAD
Assistant Professor of Dermatology at Ronald O. Perelman Department of Dermatology, NYU Medical Center

Babar K. Rao, MD
Founder and Director of Rao Dermatology NY, NJ, CA / Clinical Professor of Dermatology, Rutgers-Robert Wood Johnson Medical School / Clinical Associate Professor, Weill Cornell Medical School

Team 2: Hair Health - Find out about the breakthroughs, newer solutions and time-tested treatments for various hair health issues affecting individuals with skin of color,

led by: Dr. Amy McMichael and Dr. Andrew Alexis.

Amy McMichael, MD
Professor & Chair, Department of Dermatology, Wake Forest Baptist Health Medical Center

Andrew F. Alexis, MD, MPH
Chair, Department of Dermatology, Mount Sinai St. Luke’s & Mount Sinai Roosevelt / Associate Professor of Dermatology, Icahn School of Medicine at Mount Sinai

Team 3: Latest Science, Highest Art in Treating Pigmentary Disorders - Learn more about the scientific breakthroughs, most effective treatments, therapies and considerations for the host of pigmentary disorders, including hyper-pigmentation, PIH, melasma, and vitiligo, with special emphasis on key considerations and risks in treating skin of color. Discussion will also address when to skimp and when to spend on OTC beauty products/prescription products targeting pigmentary disorders,

led by: Dr. Marta Rendon and Dr. Seemal Desai.

Marta I. Rendon, MD
Founder Skin Care Research, Medical Director, Rendon Center for Dermatology / Clinical Associate Professor, Department of Dermatology, University of Miami School of Medicine

Seemal R. Desai, MD, FAAD
President & Medical Director, Innovative Dermatology / Clinical Assistant Professor of Dermatology, University of Texas Southwestern

Team 4: Sun Safety and Skin Cancer in Skin of Color: Myths and Truths—Know the facts, myths, and truths about skin cancer and sun protection in darker skin types,

led by: Dr. Maritza Perez and Dr. Susan Taylor.

Maritza Perez, MD
Director of Cosmetic Dermatology, St. Luke’s Roosevelt Medical Center / Associate Director of Procedural Dermatology, Beth Israel Medical Center / Clinical Professor of Dermatology, Mount Sinai Icahn School of Medicine

Susan C. Taylor, MD
Founding Co-Director, Skin of Color Center, St. Luke’s-Roosevelt Faculty, Perelman School of Medicine

Skin of Color Society Media Day Sponsors

This year’s Skin of Color Society Media Day is made possible thanks to the generosity of the following sponsors, in support of the educational mission of our Society:

aclaris_jpg Aclaris Therapeutics, Inc. is a clinical-stage dermatologist-led specialty pharmaceutical company focused on identifying, developing and commercializing innovative and differentiated therapies to address significant unmet needs in medical and aesthetic dermatology. Aclaris is based in Malvern, Pennsylvania and more information can be found by visiting the Aclaris website at www.aclaristx.com.

Recommended by more than 25,000 dermatologists worldwide, La Roche-Posay offers a unique range of daily skincare developed with dermatologists for every skin type to complement and enhance their patients’ treatments and to promote good skincare practices at home every day. Started from Europe’s leading center of thermal dermatology, La Roche-Posay develops formulas with its exclusive Selenium-rich water, used at the center since 1905 to treat over 7,500 patients every year for skin disorders thanks to its antioxidant and soothing properties. Visit: www.laroche-posay.us/

Merz Dermatology delivering a better total experience in aesthetics, dermatology and neurosciences. As part of the Merz Pharma Group, our ambition is to become the most admired, trusted and innovative aesthetics and neurotoxin company. By developing products that improve patients’ health and help them to live better, feel better and look better, we will continue to make significant contributions to the well-being of individuals around the world. Merz Dermatology‘s flagship brand, Naftin® (naftifine HCl), remains the #1 topical antifungal brand prescribed by dermatologists and podiatrists in the U.S. Merz Dermatology is an important contributor to the U.S. dermatology space, offering a well-balanced product portfolio that includes the Naftin® (naftifine HCl) family of products, Onmel™ (itraconazole) and Aluvea™ (Urea 39%) Cream. To learn more about Merz Dermatology and their U.S. product portfolio. Visit: www.merzusa.com/dermatology

nutrafol-1 Nutrafol®, a first-to-market smart-supplement for healthy hair growth, has leveraged recent innovations in biotechnology to help treat hormonal and stress related hair loss. With patent-pending formulas for both female hair loss and male hair loss, Nutrafol® has captured the hearts of key opinion leaders in the medical and salon channels nationwide. Visit: www.nutrafol.com

Procter & Gamble: Through leading brands like Olay, Art of Shaving, and Head & Shoulders, P&G is committed to understanding and improving skin. Almost all of our products touch or impact skin in some way, making our work with dermatologists crucial to so many moments experienced throughout a typical daily routine. In partnership with leading dermatologists, P&G scientists examined racial similarities and differences in both skin aging and gene expression related to sun exposure in the Multi-Decade and Ethnicity (MDE) study to better understand how to meet the needs of people around the world. This understanding leads P&G brands to create products that patients and consumers find effective and enjoyable to use, enabling a higher level of compliance. Visit: www.pg.com

The "Find a Doctor" database ("Doctor Database") is published by the Skin of Color Society ("SOCS") for educational purposes only. It is intended to provide the public with easy access to information on physicians who treat patients with skin of color and who are SOCS members. SOCS requires that any user wishing to access the Doctor Database agree to the following terms and conditions of this Access Agreement.

Specifically, users acknowledge and agree that:

The content of the Doctor Database is the property of SOCS, or used by SOCS with permission, and is protected under U.S. and international copyright and trademark laws, whether or not a notice of copyright, trademark, or other proprietary rights appears on the screen displaying the information. Individuals may save, use, download, and retransmit information from the Doctor Database only for personal, non-commercial purposes. Users shall not download, reproduce, retransmit, distribute, by sale or otherwise, edit, or otherwise use the Doctor Database for any other purpose without the expressed prior written permission of SOCS.
The names, addresses and other data in the Doctor Database has been compiled from information provided by individual physicians to SOCS and are included only to assist interested individuals in locating SOCS members who provide services in the defined city, state or other jurisdiction. Although SOCS regularly updates the Doctor Database, it expressly disclaims any and all responsibility or liability for the use or misuse of any information presented or described and makes no warranty, guarantee, or representation that such information is valid, sufficient, or complete. Unless specifically stated otherwise, SOCS does not endorse, approve, recommend, or certify any individual, service, or organization included in the Doctor Database, and such information should not be referenced in any way to imply such approval or endorsement.
Neither the Doctor Database, nor the page of the SOCS website on which they are contained, may be accessed to conduct any other activities that may be illegal. For example, they shall not be used to encourage software infringement, spreading of computer viruses, breaking into private computer forums, gambling, or other crimes.
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