When A Patient Presents With Longitudinal Nail Pigmentation

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Nail Pigment Changes That Should Undergo Biopsy

1. Isolated pigmented band on a single digit that develops during fourth to sixth decade of life (although melanoma can occur in children, it is a very rare event)
2. Nail pigmentation that develops abruptly in a previously normal nail plate
3. Pigmentation that suddenly becomes darker or larger, or pigment becomes blurred near nail matrix
4. Acquired pigmentation of thumb, index finger, or large toe
5. Pigment that develops after a history of digital trauma and in which one has ruled out subungual hematoma
6. Any acquired lesion in patients with a personal history of melanoma
7. If pigmentation is associated with nail dystrophy including partial nail destruction or absence of nail plate
8. If pigmentation of periungual skin (including lateral nailfolds) is found to be present (Hutchinson’s sign); this includes pigment of cuticle or hyponychium

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Author(s): 
M. Joel Morse, DPM

References
1. Skowron F, Combemale P, Faisant M, Baran R, Kanitakis J, Dupin M. Functional melanonychia due to involvement of the nail matrix in systemic lupus erythematosus. J Am Acad Dermatol. 2002; 47(2Suppl): S187-S188.
2. Tosti A. Diseases of hair and nails. In: Goldman L, Ausiello D (eds): Goldman’s Cecil Medicine, 24th ed. Ch. 450, Saunders Elsevier, Philadelphia, 2011.
3. Naylor EM, Ruben BS, Robinson-Bostom L, et al. Subungual blue nevus with combined phenotypic features. J Am Acad Dermatol. 2008; 58(6):1021-4.
4. Husain S, Scher RK, Silvers DN, Ackerman B. Melanotic macule of nail unit and its clinicopathologic spectrum. J Am Acad Dermatol. 2006; 54(4):664-667.
5. Grandinetti LM, Tomecki KJ. Dermatologic signs of systemic disease. In: Carey WD (ed): Cleveland Clinic: Current Clinical Medicine 2010, 2nd ed. Saunders Elsevier, Philadelphia, 2010.
6. Harwood M, Telang GH, Robinson-Bostom L, Jellinek N. Melanoma and squamous cell carcinoma on different nails of the same hand. J Am Acad Dermatol. 2008; 58(2):323-6.
7. Haneke E, Baran R. Longitudinal melanonychia. Dermatol Surg. 2001; 27(6):580-584.
8. Dominguez-Cherit J, Roldan-Marin L, Pichardo-Velazquez P, et al. Melanonychia, melanocytic hyperplasia, and nail melanoma in a Hispanic population. J Am Acad Dermatol. 2008; 59(5):785-91.
9. Hay RJ, Baran R. Onychomycosis: a proposed revision of the clinical classification. J Am Acad Dermatol. 2011; 65(6):1219-27
10. Braun RP, Baran R, Le Gal FA, et al. Diagnosis and management of nail pigmentations. J Am Acad Dermatol. 2007; 56(5):835-847.
11. Baran R. Frictional longitudinal melanonychia: a new entity. Dermatologica. 1987; 174(6):280-284.
12. Piraccini BM, Iorizzo M. Drug reactions affecting the nail unit: diagnosis and management. Dermatology Clinics. 2007; 25(2):215-21.

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