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Peer Reviewed

Photo Essay

An Atlas of Nail Disorders, Part 14

Volume 60 - Issue 12 - December 2020

AUTHORS:
Alexander K. C. Leung, MD1,2 • Benjamin Barankin, MD3 • Kin Fon Leong, MD4 • Joseph M. Lam, MD5

AFFILIATIONS:
1Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
2Alberta Children’s Hospital, Calgary, Alberta, Canada
3Toronto Dermatology Centre, Toronto, Ontario, Canada
4Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia

5Department of Pediatrics and Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada

CITATION:
Leung AKC, Barankin B, Leong KF, Lam JM. An atlas of nail disorders, part 14. Consultant. 2020;60(12):21-23. doi:10.25270/con.2020.12.00002

DISCLOSURES:
The authors report no relevant financial relationships.

CORRESPONDENCE:
Alexander K. C. Leung, MD, #200, 233 16th Ave NW, Calgary, AB T2M 0H5, Canada (aleung@ucalgary.ca)

EDITOR’S NOTE:
This article is part 14 of a 15-part series of Photo Essays describing and differentiating conditions affecting the nails. Part 15 will be published in an upcoming issue of Consultant. To access previously published articles in the series, visit the Consultant archive at www.Consultant360.com and click the “Journals” tab.

Subungual Hematoma

Subungual hematoma is caused by bleeding under the nail in the underlying vascular nail bed, most often as a result of trauma to the digit. The trauma may be in the form of direct blow, blunt trauma, or a crush injury to the distal phalanx.1 Toenails are affected more often than fingernails. In this regard, the great toe is most often affected in tennis players, the second and third toes in squash and soccer players, and the fifth toe in joggers.2 Other causes of subungual hematoma include the use of medications (eg, anticoagulants, chemotherapeutic agents, acitretin, ganciclovir) and systemic diseases (eg, diabetes, systemic lupus erythematosus).3-6

Subungual hematomas of recent onset are extremely painful and appear red-purple to purple-black.2 With time, they become less painful, the color changes to black (Figure 1), dark blue, purple, blue, or yellow-green due to breakdown of hemosiderin, and the border may become blurry (Figure 2).2

Subungual hematoma Figure 1
Figure 1.

Subungual hematoma Figure 2
Figure 2.

A subungual hematoma will migrate distally with the growth of the nail, exhibiting a proximal border that reproduces the shape of the lunula, whereas most of the other causes of melanonychia and pigmented lesions of the nail matrix or nail bed will remain stationary.7-10 Also, there is often a history of trauma to the affected nail. Dermoscopic findings of red, black, purple, dark blue, or brown areas of homogeneous pigmentation, followed by globules, are characteristic of subungual hemorrhage.11-13 Transillumination of the nail combined with dermoscopy might further enhance the diagnostic accuracy.13 For a traumatic subungual hematoma, a 3-view radiograph of the involved digit should be considered if an underlying fracture is suspected.2

Most subungual hematomas of recent onset (usually less than 48 hours) can be successfully treated with simple trephination with immediate relief of pain.1,2,14 In this regard, patients with nontraumatic development of subungual hematomas might not benefit from trephination.1

REFERENCES:

  1. Pingel C, McDowell C. Subungual hematoma drainage. StatPearls. Updated July 31, 2020. Accessed November 2, 2020. https://www.ncbi.nlm.nih.gov/books/NBK482508/
  2. Cohen PR, Schulze KE, Nelson BR. Subungual hematoma. Dermatol Nurs. 2007;19(1):83-84.
  3. Aydogan K, Karadogan SK, Tunali S. Acitretin-induced subungual hemorrhage. Int J Dermatol. 2007;46(5):494-495. doi:10.1111/j.1365-4632.2006.03059.x
  4. Chieb S, Baha H, Hali F. Subungual hematoma: clinical appearance of resolution over time. Dermatol Online J. 2015;21(10):13030/qt689871cb.
  5. Vanhooteghem O, André J, Vindevoghel A, Vandenbossche L, Vandeveire A, Song M. Docetaxel-induced subungual hemorrhage. Dermatology. 1997;194(4):419-420. doi:10.1159/000246166
  6. Zhang S, Liu X, Cai L, Zhang J, Zhou C. Longitudinal melanonychia and subungual hemorrhage in a patient with systemic lupus erythematosus treated with hydroxychloroquine. Lupus. 2019;28(1):129-132. doi:10.1177/0961203318812685
  7. André J, Lateur N. Pigmented nail disorders. Dermatol Clin. 2006;24(3):329-339. doi:10.1016/j.det.2006.03.012
  8. Haneke E, Baran R. Longitudinal melanonychia. Dermatol Surg. 2001;27(6):580-584.
  9. Leung AKC, Woo TY. Melanonychia striata with multiple toenail involvement in a child. J Natl Med Assoc. 2004;96(9):1232-1234.
  10. Leung AKC, Lam JM, Leong KF, Sergi CM. Melanonychia striata: clarifying behind the Black Curtain. A review on clinical evaluation and management of the 21st century. Int J Dermatol. 2019;58(11):1239-1245. doi:10.1111/ijd.14464
  11. Decker A, Connolly KL, Lee EH, Busam KJ, Nehal KS. Frequency of subungual melanoma in longitudinal melanonychia: a single-center experience. Dermatol Surg. 2017;43(6):798-804. doi:10.1097/DSS.0000000000001112
  12. Di Chiacchio N, Ruben BS, Loureiro WR. Longitudinal melanonychias. Clin Dermatol. 2013;31(5):594-601. doi:10.1016/j.clindermatol.2013.06.007
  13. Kaliyadan F, Ashique KT. Nail transillumination combined with dermoscopy for enhancing diagnosis of subungual hematoma. Indian Dermatol Online J. 2018;9(2):105-106. doi:10.4103/idoj.IDOJ_295_17
  14. Pirzada A, Waseem M. Subungual hematoma. Pediatr Rev. 2004;25(10):369. doi:10.1542/pir.25-10-369

 

Splinter Hemorrhage

Splinter hemorrhages typically appear as reddish brown (when fresh or as a result of systemic disease) to black (within days), small, thin, longitudinal streaks, usually 1 to 3 mm in length, in the nail bed under the nail plate (Figures 1 and 2).1,2

Splinter hemorrhage Figure 1
Figure 1.

Splinter hemorrhage Figure 2
Figure 2.

These longitudinal lines arise from damaged capillaries in the longitudinally oriented epidermal-dermal ridges in the nail bed, with resultant leakage of blood from the capillaries.1 Splinter hemorrhages do not blanch on pressure and are usually asymptomatic.1,2 The condition is more common in males than in females and in African Americans than in Whites.1,3 Splinter hemorrhages occur mostly on the fingernails rather than on the toenails.1 In healthy individuals, splinter hemorrhages are usually confined to a single digit.1 In contrast, multiple digit involvement is more consistent with a systemic causation.4

The most common causes of splinter hemorrhages are trauma (most commonly, occupation-related or sport-related, but should also include onychophagia), followed by nail psoriasis.1,3-7 Other causes include infectious diseases (eg, septicemia, subacute bacterial endocarditis, fungal endocarditis, onychomycosis, meningococcemia, trichinosis, histoplasmosis), tick bite, blood dyscrasias (eg, leukemia, thrombocytopenia purpura), cutaneous T-cell lymphoma, nail tumors (eg, onychopapilloma, onychomatricoma), chronic dermatitis (eg, lichen planus, eczema, Darier disease), connective tissue diseases (eg, systemic lupus erythematosus, rheumatoid arthritis, antiphospholipid syndrome, Raynaud disease, hypereosinophilic vasculitis), medications (eg, warfarin, aspirin, sorafenib, sunitinib, cabozantinib, zolpidem, tetracycline, terbinafine), chronic kidney disease (especially those who require hemodialysis or peritoneal dialysis), endocrine diseases (eg, diabetes, thyrotoxicosis, hypoparathyroidism), gastrointestinal tract diseases (eg, peptic ulcer disease, cirrhosis, hemochromatosis), internal malignancy, scurvy, hypertension, exposure to high altitude, radial artery puncture, local radiation, sarcoidosis, tuberous sclerosis complex, Langerhans cell histiocytosis, hereditary hemorrhagic telangiectasia, Behçet disease, granulomatosis with polyangiitis, and thromboangiitis obliterans (Buerger disease).1,4,8-32 Idiopathic atraumatic splinter hemorrhages can occur in healthy individuals.4

In general, idiopathic splinter hemorrhages and splinter hemorrhages as a result of trauma are more commonly located in the distal third of the nail (Figures 1 and 2). In contrast, splinter hemorrhages as a result of systemic diseases are usually proximal in location. Splinter hemorrhages as a result of bacterial endocarditis typically appear in the mid-portion of the nail.2

The diagnosis is mainly clinical, based on the characteristic physical findings. In general, splinter hemorrhages move distally as the nail grows, since the extravasated blood usually attaches to the nail plate.3 Occasionally, splinter hemorrhages remain stationary if the blood attaches to the nail bed rather than the nail plate.3

REFERENCES:

  1. Haber R, Khoury R, Kechichian E, Tomb R. Splinter hemorrhages of the nails: a systematic review of clinical features and associated conditions. Int J Dermatol. 2016;55(12):1304-1310. doi:10.1111/ijd.13347
  2. Tully AS, Trayes KP, Studdiford JS. Evaluation of nail abnormalities. Am Fam Physician. 2012;85(8):779-787.
  3. Han MJ, Bidinger JJ, Hivnor CM. Asymptomatic linear hemorrhages. Splinter hemorrhages. Am Fam Physician. 2010;81(11):1375-1376.
  4. Salem A, Al Mokadem S, Attwa E, Abd El Raoof S, Ebrahim HM, Faheem KT. Nail changes in chronic renal failure patients under haemodialysis. J Eur Acad Dermatol Venereol. 2008;22(11):1326-1331. doi:10.1111/j.1468-3083.2008.02826.x
  5. Fıçıcıoğlu S, Korkmaz S. Onychophagia induced melanonychia, splinter hemorrhages, leukonychia, and pterygium inversum unguis concurrently. Case Rep Dermatol Med. 2018;2018:3230582. doi:10.1155/2018/3230582
  6. Haneke E. Nail psoriasis: clinical features, pathogenesis, differential diagnoses, and management. Psoriasis (Auckl). 2017;7:51-63. doi:10.2147/PTT.S126281
  7. Sobolewski P, Walecka I, Dopytalska K. Nail involvement in psoriatic arthritis. Reumatologia. 2017;55(3):131-135. doi:10.5114/reum.2017.68912
  8. Alzayer H, Hasan MA. Hypereosinophilic vasculitis: a case report. Medicine (Baltimore). 2019;98(17):e15392. doi:10.1097/MD.0000000000015392
  9. Bishop BE, Wulkan A, Kerdel F, El-Shabrawi-Caelen L, Tosti A. Nail alterations in cutaneous T-cell lymphoma: a case series and review of nail manifestations. Skin Appendage Disord. 2015;1(2):82-86. doi:10.1159/000433474
  10. Bitterman R, Oren I, Geffen Y, Sprecher H, Schwartz E, Neuberger A. Prolonged fever and splinter hemorrhages in an immunocompetent traveler with disseminated histoplasmosis. J Travel Med. 2013;20(1):57-59. doi:10.1111/jtm.12000
  11. Cho YT, Chan CC. Cabozantinib-induced hand-foot skin reaction with subungual splinter hemorrhages and hypertension: a possible association with inhibition of the vascular endothelial growth factor signaling pathway. Eur J Dermatol. 2013;23(2):274-275. doi:10.1684/ejd.2013.1930
  12. Elmansour I, Chiheb S, Benchikhi H. Nail changes in connective tissue diseases: a study of 39 cases. Pan Afr Med J. 2014;18:150. doi:10.11604/pamj.2014.18.150.4637
  13. Gibson GE, Su WPD, Pittelkow MR. Antiphospholipid syndrome and the skin. J Am Acad Dermatol. 1997;36(6 pt 1):970-982. doi:10.1016/s0190-9622(97)80283-6
  14. Hirai T, Koster M. Osler’s nodes, Janeway lesions and splinter haemorrhages. BMJ Case Rep. 2013;2013:bcr2013009759. doi:10.1136/bcr-2013-009759
  15. Iftikhar SF, Ahmad F. Tricuspid valve endocarditis. StatPearls. Updated July 10, 2020. Accessed November 2, 2020. https://www.ncbi.nlm.nih.gov/books/NBK538423/
  16. Kolla PK, Desai M, Pathapati RM, et al. Cutaneous manifestations in patients with chronic kidney disease on maintenance hemodialysis. ISRN Dermatol. 2012;2012:679619. doi:10.5402/2012/679619
  17. Komori T, Otsuka A, Cho M, Honda T, Kabashima K. Nail pitting and splinter hemorrhage possibly induced by zolpidem. J Dermatol. 2019;46(5):e151-e152. doi:10.1111/1346-8138.14715
  18. Leung AKC, Leong KF, Barankin B. Hereditary hemorrhagic telangiectasia. J Pediatr. 2019;210:232. doi:10.1016/j.jpeds.2019.03.013
  19. Leung AKC, Lam JM, Leong KF. Childhood Langerhans cell histiocytosis: a disease with many faces. World J Pediatr. 2019;15(6):536-545. doi:10.1007/s12519-019-00304-9
  20. Mandrell J. Onychomatricoma: a rare case of unguioblastic fibroma of the fingernail associated with trauma. Cutis. 2016;97(4):E15-E18.
  21. Mulroy E, Cleland J, Anderson NE. Crescentic splinter haemorrhages reflect stroke pathophysiology in hypereosinophilic syndrome. Australas J Dermatol. 2018;59(3):e211-e212. doi:10.1111/ajd.12717
  22. Musher DM. Ascent to altitude: a benign cause of splinter hemorrhages. J Travel Med. 2012;19(4):253-254. doi:10.1111/j.1708-8305.2012.00608.x
  23. Quenneville JG, Gossard D. Subungueal-splinter hemorrhage an early sign of thromboangiitis obliterans. Angiology. 1981;32(6):424-432. doi:10.1177/000331978103200609
  24. Ramasamy C, Dubashi B, Rekha JS, Basu D, Jain A, Dutta TK. Hairy cell leukemia masquerading as infective endocarditis. Indian J Hematol Blood Transfus. 2013;29(2):84-86. doi:10.1007/s12288-011-0132-9
  25. Saladi RN, Persaud AN, Rudikoff D, Cohen SR. Idiopathic splinter hemorrhages. J Am Acad Dermatol. 2004;50(2):289-292. doi:10.1016/j.jaad.2003.07.012
  26. Santhamkumar C, Faddoul C, Barker R, Facer R, Limaye S. Lesson of the month 1: splinter haemorrhages as a pointer to gastrointestinal malignancy. Clin Med (Lond). 2016;16(2):199-200. doi:10.7861/clinmedicine.16-2-199
  27. Sethi K, Buckley J, de Wolff J. Splinter haemorrhages, Osler’s nodes, Janeway lesions and Roth spots: the peripheral stigmata of endocarditis. Br J Hosp Med (Lond). 2013;74(9):C139-C142.
  28. Shaath T, Fischer R, Goeser M, Rajpara A, Aires D. Scurvy in the present times: vitamin C allergy leading to strict fast food diet. Dermatol Online J. 2016;22(1):13030/qt50b8w28b.
  29. Sohn KH, Oh SY, Lim KW, Kim MY, Lee SY, Kang HR. Sorafenib induces delayed-onset cutaneous hypersensitivity: a case series. Allergy Asthma Immunol Res. 2015;7(3):304-307. doi:10.4168/aair.2015.7.3.304
  30. Tan C, Zhu WY. Splinter haemorrhages associated with oral terbinafine in a Chinese man. Clin Exp Dermatol. 2006;31(1):153-154. doi:10.1111/j.1365-2230.2005.01978.x
  31. Uhlenhake EE, Watson AC, Aronson P. Sorafenib induced eruptive melanocytic lesions. Dermatol Online J. 2013;19(5):18184.
  32. van der Werf TS, Tulleken JE, Zijlstra JG. Recurrent splinter haemorrhages weeks after a tick bite. Neth J Med. 2004;62(7):260-264.