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Dermoscopic Examination of Nail Pigmentation
Sandra Ronger, MD, PhD;
Sandrine Touzet, MD;
Claire Ligeron, MD;
Brigitte Balme, MD;
Anne Marie Viallard, MD;
Danièle Barrut, MD;
Cyrille Colin, MD, PhD;
Luc Thomas, MD, PhD
Arch Dermatol. 2002;138:1327-1333.
ABSTRACT
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Background Diagnosis of longitudinal melanonychia is usually difficult, and neither
a single clinical criterion nor a combination of symptoms currently can be
used to clearly distinguish malignant from benign bandlike pigmented nail
lesions. Biopsy is painful and often leaves definitive dystrophic scars.
Objectives To describe and evaluate dermoscopic patterns associated with longitudinal
nail pigmentation.
Patients and Methods A total of 148 unselected consecutive cases of longitudinal melanonychia
were included over a period of 4 years (20 melanoma, 37 nevi, 16 drug-induced
nail pigmentation, 45 nail apparatus lentigo of various types, 8 ethnic-type
nail pigmentation, and 22 subungual hemorrhages). All patients were recruited
from the dermatology unit outpatient clinic of the Hôtel Dieu de Lyon.
All cases were photographed in vivo under oil immersion (dermoscopy). Patterns
were recorded prior to final pathologic diagnosis. An independent biostatistics
unit performed statistical evaluation using 7 semiologic patterns.
Results Melanoma cases were significantly associated with a brown coloration
of the background and the presence of irregular longitudinal lines (P = .001). Blood spots were mostly observed in subungual hemorrhages
(P = .001); however, their presence could not rule out melanoma.
Micro–Hutchinson sign was observed only in melanoma, but its rare occurrence
did not allow any statistical evaluation of its specificity. Nail apparatus
nevi were significantly associated with a brown coloration of the background
and the presence of regular lines (P = .001). Nail apparatus
lentigo, ethnic-type pigmentation, and drug-induced pigmentation were significantly
associated with homogeneous longitudinal thin gray lines and gray coloration
of the background (P = .001). Microscopic longitudinal grooves
were unspecific, occurred in several conditions, and were associated with
any type of ungual discoloration.
Conclusions We believe that dermoscopic examination of the nail plate in cases of
longitudinal melanonychia provides useful information that could help clinicians
to more accurately decide if a nail apparatus biopsy should be performed;
however, histopathologic diagnosis remains the gold standard in doubtful cases.
INTRODUCTION
EARLY DIAGNOSIS of nail apparatus melanoma in its pigmented form is
difficult because several benign conditions share the same clinical features
(ie, longitudinal melanonychia).1-14 Several
clinical criteria have been proposed to help clinicians more accurately distinguish
suggestive cases,15 but neither a single clinical
criterion nor a combination of symptoms currently can be used to avoid numerous
useless painful nail matrix biopsies that may leave dystrophic scars.16-19 Longitudinal
melanonychia is suggestive when it is unique, polychrome, increasing in width,
or accompanied by the Hutchinson sign (pigmentation of the cuticle). Also
suggestive are onset during adulthood, absence of history of pigmentation-inducing
treatment, and ethnic origin not usually associated with nail pigmentation.
Indications of probable benign multiple lesions are phototype V or VI skin
or lesions present since childhood.15
The literature on dermoscopic examination of the nails is limited to
very few published observations,20-23 in
contrast to the large body of information available on dermoscopy of pigmented
lesions elsewhere on the skin.24-27 The
goals of our study were to (1) systematically examine under oil immersion
(dermoscopy) a large consecutive cohort of patients referred to our center
for pigmented band(s) on nails; (2) try to individualize relevant dermoscopic
patterns; and (3) evaluate pattern correlation with 6 different etiologic
diagnoses (melanoma, nevus, drug-induced nail pigmentation, nail apparatus
lentigo, ethnic-type nail pigmentation, and subungual hemorrhages).
PATIENTS AND METHODS
A total of 148 unselected consecutive cases of longitudinal melanonychia
were included in this study over a period of 4 years (20 melanoma, 37 nevi,
16 drug-induced nail pigmentation, 45 nail apparatus lentigo of various types,
8 ethnic-type nail pigmentation, and 22 subungual hemorrhages). All patients
were recruited from the dermatology unit outpatient clinic of the Hôtel
Dieu de Lyon; informed consent was obtained. All cases were photographed under
oil immersion with a dermoscopic camera (Heine Dermaphot, Herrshing, Germany).
All pictures were taken prior to biopsy, and observed features were recorded
without any knowledge of the final pathologic diagnosis. The final diagnosis
was based on pathologic examination of a representative nail matrix biopsy
specimen as well as records of the patient's medical history (especially pigmentation-inducing
drug treatments and repetitive trauma or inflammation of the nail region),
ethnic origin, total skin and mucous membrane examination (especially centered
on the detection of the various types of lentiginoses such as Laugier-Hunziker
disease), and postoperative evolution of the lesion with a minimum follow-up
of 6 months. Twenty cases of melanoma were included (all acral lentiginous
melanoma), with a mean Breslow thickness of 1.07 mm (range, 0.2-2.1 mm); 2
cases were Clark level I melanomas, all other cases were invasive. Thirty-seven
cases were nail apparatus melanocytic nevi; 45 corresponded to nail apparatus
lentigo (among which 12 cases were part of a Laugier-Hunziker syndrome and
1 corresponded to Peutz-Jeghers-Touraine syndrome).
Previous observations allowed us to individualize 7 distinct dermoscopic
features of longitudinal melanonychia (Figure
1). These features were recorded for all cases prior to biopsy:
(1) Blood spots were characterized by proximally
well-circumscribed dots or blotches. Their coloration varied from purple-blue
in recent lesions to brown in older lesions, and the distal edge was in some
cases distorted with a somewhat linear pattern, especially in older lesions
(Figure 2). (2) Brown coloration of the background in the area of the clinically observed
dark band varied from light to dark with sharply delimited lateral borders.
The proximal border corresponded in most cases to the proximal nail plate
immediately adjacent to the cuticle; the distal border corresponded to the
distal edge of the nail plate (Figure 3, Figure 4, Figure 5, and Figure 6).
In most cases this background was associated with either regular or irregular
lines. (3) Regular lines, usually associated with
the brown background, displayed regularity in coloration, spacing, and thickness;
no disruption in their parallelism was observed (Figure 3). (4) Irregular lines were also
usually associated with a brown background and showed variations in coloration,
spacing, and thickness. Some areas of disruption in parallelism were also
observed (Figure 4 and Figure 5). (5) Grayish
background in the area of the clinically observed band varied from
light to dark (Figure 7). Thin gray
lines regular in coloration, thickness, and spacing were usually associated
with this gray background (Figure 8).
(6) Micro–Hutchinson sign was defined by the
visibility on dermoscopy of a pigmentation of the periungual tissues that
could not be seen with the naked eye (Figure
6). (7) Microscopic grooves were observed
in many cases, not always superimposed on the pigmented area. These grooves
were either whitish or grayish and had a linear longitudinal disposition (Figure 9).
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Figure 1. Schematic representations of the
7 dermoscopic patterns observed in longitudinal melanonychia: A, blood spots;
B, brown coloration of the background; C, regular lines; D, irregular lines;
E, grayish background and thin gray lines; F, micro–Hutchinson sign;
and G, microscopic grooves.
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Figure 2. Purple to brown blood spots are
seen in a subungual hemorrhage in a 67-year-old man. The proximal edge of
the spot is usually rounded (short arrows), while the distal edge has a somewhat
linear distortion pattern (long arrows).
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Figure 3. Nail apparatus melanocytic nevus
in an 8-year-old boy. Note the brown coloration of the background (long arrow)
and the thin, darker longitudinal lines with regular thickness, spacing, and
coloration (short arrows).
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Figure 4. Nail apparatus acral lentiginous
melanoma, Clark level III (1.7-mm Breslow thickness) in a 57-year-old woman.
Dermoscopy disclosed a brown coloration of the background (long arrow) and
darker longitudinal lines with irregular thickness, coloration, and spacing
(double arrows). Disruptions of parallelism were also observed (short arrows).
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Figure 5. Nail apparatus acral lentiginous
melanoma, Clark level II (0.9-mm Breslow thickness), in a 71-year-old man.
Dermoscopy shows a brown background and longitudinal darker lines of irregular
thickness, spacing, and coloration (arrows).
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Figure 6. Nail apparatus acral lentiginous
melanoma in situ, Clark level I (0.2-mm Breslow thickness), in a 72-year-old
woman. A, The clinical view shows no evidence of pigment in the cuticle area;
B, the dermoscopic image shows irregular lines overlying a brown background
and a micro–Hutchinson sign (arrow).
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Figure 7. Hydroxyurea-induced longitudinal
melanonychia in an 81-year-old man treated for chronic lymphocytic leukemia.
Dermoscopy shows a grayish coloration of the background (long arrows) and
thin regular longitudinal gray lines (short arrows).
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Figure 8. Nail apparatus lentigo in a 37-year-old
woman with Laugier-Hunziker disease. Dermoscopy reveals a brown coloration
of the background (long arrow) and mostly regular, thin, longitudinal gray
lines (short arrows).
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Figure 9. Ethnic-type nail pigmentation
in a 42-year-old man of Gypsy lineage. Dermoscopy reveals a grayish coloration
of the background and longitudinal microscopic grooves either associated (short
arrows) or not (long arrow) with the pigmentation.
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Observed features and final diagnoses were cross tablulated at the end
of the study, and statistical analysis was performed by an independent biostatistics
unit using the  2 test or, in case of a small number of recorded
events, Fisher exact test (SAS software; SAS Institute, Cary, NC). Results
gave significance scores for all differential diagnoses of melanoma. P values of .05 or lower were considered significant.
RESULTS
NAIL APPARATUS MELANOMA
The results of all analyses are summarized in Table 1. Twenty cases of nail apparatus melanoma were included in
the study. Prominent dermoscopic features observed in melanoma were the association
of brown pigmentation of the background (19/20; 95%) with longitudinal brown
to black lines irregular in their coloration, spacing, thickness, and parallelism
(19/20; 95%) (Table 1, Figure 1B, Figure 1D, Figure 4, and Figure 5). The irregular pattern of the lines
was significantly associated with melanoma when compared with all other diagnoses
(P = .001) taken either individually or as a group
(P = .001 in all 5 differential diagnoses). Melanoma
shared with melanocytic nevus the brown coloration of the background. The
micro–Hutchinson sign as defined by the visibility of a pigmentation
of the cuticle only on dermoscopy (Figure
1F and Figure 6) was observed
in only 3 cases, but all were melanoma. This rare feature was also significantly
associated with melanoma when compared with all other diagnoses (P = .001). Interestingly blood spots were observed in 1 case of melanoma;
their presence, therefore, cannot rule out this diagnosis.
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Cross Tabulation Between Dermoscopic Patterns and Dermatologic Diagnoses*
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NAIL APPARATUS MELANOCYTIC NEVUS
Thirty-seven cases of melanocytic nevus of the nail were included in
the study. Prominent observed features were the brown background (37/37; 100%)
and the regular pattern of the longitudinal lines (35/37; 95%) (Figure 3). The presence of these lines, regular in their thickness,
spacing, coloration, and parallelism, was found statistically sufficient to
distinguish nevus from melanoma (P = .001).
DRUG-INDUCED NAIL PIGMENTATION
Sixteen cases of drug-induced nail pigmentation were included in this
study. In most cases the pigmentation was observed on several fingernails
or toenails. The 3 most frequently recorded responsible drugs were zidovudine
(AZT), hydroxyurea, and minocycline. The main dermoscopic features in these
cases were a grayish coloration of the background (15/16; 94%) and the presence
of thin longitudinal gray lines with regular thickness, spacing, coloration,
and absence of parallelism disruption (Figure
7). These dermoscopic findings were not different from the ones
observed in ungual lentigo or ethnic-type pigmentation but significantly differed
from melanoma (P = .001).
UNGUAL LENTIGO
Forty-five cases of nail apparatus lentigo of various types were included
in the study. Most cases were isolated, but 12 cases were part of a Laugier-Hunziker
syndrome,28 and 1 corresponded to Peutz-Jeghers-Touraine
syndrome. Dermoscopic findings were similar to those observed in drug-induced
pigmentation or in ethnic-type melanonychia. Prominent features were the grayish
coloration of the background (44/45; 98%) and the presence of thin longitudinal
gray lines regular in their coloration, thickness, and spacing (42/45; 93%).
The presence of these 2 criteria significantly differentiated nail lentigo
from melanoma (P = .001).
ETHNIC-TYPE NAIL PIGMENTATION
Eight cases of ethnic-type pigmentation of the nail were included in
the study. In most cases the pigmented longitudinal bands were multiple on
fingernails and/or toenails. The patterns in these cases were similar to those
previously described in ungual lentigo and drug-induced nail pigmentation
but significantly different from those of melanoma (P =
.001). The 2 characteristic dermoscopic features of ethnic-type nail pigmentation
were the grayish background (7/8; 87.5%) and the thin, regular gray lines
(7/8; 87.5%).
SUBUNGUAL HEMORRHAGE
In the present study, 22 cases of subungual hemorrhage were included.
Only cases with a longitudinal bandlike disposition of the pigmentation were
included to evaluate situations in which melanoma could be included in the
clinical differential diagnosis of the lesion. Blood spots characterized by
a well-limited, rounded proximal edge and a purple to brown coloration were
observed in all cases of subungual hemorrhages (22/22; 100%). The distal edge
of older lesions showed a somewhat linear distortion that could rarely result
in the formation of either regular of irregular lines. It is important to
note that, even though the blood spot pattern was significantly associated
with subungual hemorrhages when compared with melanoma (P = .001), this easily recognizable pattern cannot be considered to
be exclusive, and its presence is not sufficient to rule out melanoma.
COMMENT
Early diagnosis and treatment of melanoma hold out the only possibility
of curative treatment.29-32 Nail
apparatus melanoma in its pigmented form is usually revealed by a longitudinal
pigmentation of the nail plate or melanonychia striations.9-14 This
clinical presentation is common to several other diagnoses,33-34 and
positive diagnosis is based on histopathologic examination of a biopsy specimen
of the nail matrix.35 This procedure is usually
painful and often followed by the creation of definitive nail dystrophy due
to the surgical injury to the nail matrix.16-19 Different
opinions have been expressed about the management of longitudinal melanonychia.36-38 Some authors recommend
systematic biopsy39; others propose histopathologic
diagnosis in suggestive cases only.15 From
the clinical point of view, suggestive lesions have their onset during adulthood,
are localized on only the nail, range in color from light brown to black,
enlarge progressively, and are associated with a pigmentation of the eponychium
called Hutchinson sign.40-44 In
contrast, lesions are more likely to be benign if there is a history of inflammatory
disease of the nail or pigmentation-inducing drug intake, if similar lesions
are found on several nails, if the onset of the lesion was in childhood,45-47 if the pigmentation
is regular, and if Hutchinson sign is absent.48
Dermoscopy is thought to be a useful tool in the diagnosis of skin pigmented
lesions. Several algorithms have been proposed to accurately diagnose melanoma,
nevi, seborrheic keratoses, pigmented basal cell carcinomas, and hemangiomas
on skin.24-27 Some
dermoscopy studies of pigmentation of the nail have been published, but no
clear attempt to establish a semiologic classification of such cases has been
produced. In their textbook, Stolz et al22 proposed
5 cases of dermoscopic examination of nail pigmentation. Two cases concerned
subungual hemorrhages and showed features very similar to those classified
as "blood spots" in the present study: the proximal edges of the spots were
rounded, whereas the distal edges had a somewhat linear pattern. A third case
was classified as mixed bacterial and fungal infection. Our experience in
such cases is similar, but we did not include this diagnosis in our study.
The fourth case was an invasive acral lentiginous melanoma, and the observed
pattern consisted of irregular lines with a brown background. The last case
showed vascular changes in scleroderma, which was not the object of our work.
Johr and Izakovic21 recently published
a report of 4 cases of nail pigmentation observed by dermoscopy. In the first
case, the longitudinal melanonychia was associated with an epithelial inclusion
cyst. No melanocytic hyperplasia was found, and the dermoscopic pattern was
homogeneous and light grayish-brown, somewhat similar to the gray homogeneous
pattern we observed in subungual lentigo. Their second case was an invasive
acral lentiginous melanoma with a dermoscopic pattern of irregularly thick,
spaced, and colored lines with a brown background. The third case was a histopathologically
proven nail apparatus nevus, and the authors described a symmetrical disposition
of parallel brown lines on dermoscopy. The last case corresponded to a benign
possibly ethnic-type nail pigmentation with a grayish homogeneous pattern
on dermoscopy. No biopsy was performed. These authors concluded that asymmetry
in color and in disposition of the pigmentation suggested high-risk lesions.
They proposed that dermoscopic examination be included in the clinical evaluation
of longitudinal melanonychia prior to biopsy and suggested that biopsy be
performed only in high-risk lesions. They also suggested that dermoscopic
follow-up could help in the proper management of such cases.
Kawabata and coworkers20 examined by
dermoscopy 6 cases of nail apparatus melanoma and 18 cases of ungual nevi.
Melanoma cases were characterized by an irregular pattern of the pigmented
lines, whereas nevi showed a more regular pattern of pigmented lines. Our
findings are therefore very similar to theirs regarding the pigmentation of
the nail plate. These authors emphasize the semiologic value of the irregular
pigmentation of the periungual tissues (Hutchinson sign) for the diagnosis
of melanoma; they found this pigmentation in all 6 of their cases. However,
in our cases, we could not calculate the significance score of this pigmentation
because of its relative rarity. Members of our research group23 recently
described a distinct dermoscopic pattern with a rounded blue homogeneous coloration
in a subungual blue nevus. However, this observation cannot be compared with
the cases included in the present study because the lesion was not clinically
characterized by a longitudinal melanonychia.
In the present study, our data indicate that brown coloration of the
background is associated with prominent melanocytic hyperplasia either in
subungual nevi or in melanoma. In contrast, lesions associated with mild hyperplasia
of melanocytes (lentigo of various types) or hyperpigmentation of the epithelium
without melanocytic hyperplasia (drug-induced or ethnic-type pigmentation)
are characterized by a grayish coloration of the background. The most powerful
criterion suggestive of melanoma was the irregularly colored, spaced, and
thick pattern of the lines with areas of disruption of their parallelism.
We confirmed that subungual hemorrhages are easily recognizable by their blue
to black structureless blood spots with a rounded proximal edge. We would
like to stress that the presence of such blood spots alone cannot rule out
melanoma; the absence of other features, especially lines, must be confirmed
to do that.
Our data confirm the previously expressed opinion that dermoscopy can
help clinicians accurately decide if a biopsy of the nail apparatus is necessary
in cases of longitudinal melanonychia. We did not demonstrate that dermoscopic
follow-up of patients with nail pigmentation would be of any value, but we
believe that further work should be done to clearly define criteria for high-risk
lesions in cases of change in the dermoscopic pattern during follow-up.
In conclusion, our findings indicate that dermoscopy should be included
in the clinical evaluation of longitudinal nail pigmentation. We believe that
irregularly thick, spaced, parallel, and colored lines associated with a brown
background are strongly suggestive of melanoma. We believe that careful examination
under oil immersion of the nail in some cases of longitudinal melanonychia
could avoid unnecessary painful surgery. Dermoscopy, of course, adds new criteria
for diagnosis of ungual pigmentation, but it does not replace histopathologic
diagnosis, and biopsy should be performed in cases of doubtful lesions. Further
studies are needed to evaluate the role of dermoscopic examination of the
nails in the clinical follow-up of patients with nail pigmentation.
AUTHOR INFORMATION
Accepted for publication April 16, 2002.
This work has been supported in part by the Insitut National pour la
Recherche Médicale, INSERM U346, and by research grants (appel d'offres
2000) from the Hospices Civils de Lyon (Dr Thomas), Lyon, France.
This study was presented in part at the First International Dermoscopy
Meeting, Rome, Italy, February 24, 2001.
Corresponding author and reprints: Luc Thomas, MD, PhD, Dermatology
Unit, Hôtel Dieu de Lyon, 69288 Lyon CEDEX 02, France (e-mail: luc.thomas{at}chu-lyon.fr).
From the Dermatology Unit, Hôtel Dieu de Lyon (Drs Ronger, Ligeron,
Balme, Viallard, Barrut, and Thomas), INSERM U346 (Drs Ronger and Thomas),
and the Technology Assessment Unit, Department of Medical Information, Hôpitaux
de Lyon (Drs Touzet and Colin), Lyon, France.
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