Case 14 2026: Nail removal and punch biopsy - Subungual Melanoma

Linnea Kristensen Ejiofor

Journal of Plastic, Breast & Reconstructive Surgery·Rapports de cas chirurgicaux en libre accès, évalués par les pairsÉvalué par les pairs · Libre accès

Case 14 2026: Nail removal and punch biopsy - Subungual Melanoma · JPBRS

Rapport de cas

Case 14 2026: Nail removal and punch biopsy - Subungual Melanoma

Linnea Kristensen Ejiofor¹

¹Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, and Magnus Balslev Avnstorp, Specialist plastic surgeon, Zealand University Hospital, Roskilde

Publié 28 mai 2026238 vues7 min de lecture

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Résumé

Nail changes can reflect a wide spectrum of benign and malignant conditions, making accurate clinical evaluation essential. This case report reviews key background knowledge on common nail alterations and their differential diagnoses. It aims to support clinicians in recognizing when a nail biopsy is indicated and outlines practical considerations for performing the procedure. In addition, the report describes essential steps in the biopsy technique and provides guidance on appropriate postoperative management and follow-up. Patient medical history A 72-year-old man was referred to the department of plastic surgery and breast surgery at Zealands University Hospital, Roskilde, on suspicion of malignant melanoma under the nail of his right thumb. Before and After Patient examination The patient presented with hutchinson’s sign, longitudinal melanonychia and no swollen lymphnodes. He had no first-degree relatives with melanoma, no prior history of melanoma (invasive or in situ) and no prior history of other skin cancers. Pre-operative considerations Background on Subungual Melanoma (SM) SM is a rare but serious malignancy arising from the nail matrix. Early diagnosis is crucial for treatment and prognosis. Nail changes are often benign; however, malignancy must always be considered in cases of pigmented nail lesions, particularly longitudinal brown or black streaks (longitudinal melanonychia). Biopsy is required when diagnostic uncertainty persists after clinical and dermoscopic evaluation. The incidence of SM is not directly associated with ethnicity in terms of increased risk; however, SM accounts for up to 33% of all melanoma cases in individuals wi

Points clés à retenir

Conseils pratiques

• Use ultrasound gel rather than alcohol under the dermatoscope.
• Apply a digital tourniquet to create a bloodless field, improving visualization of tissue structures and providing crucial hemostasis.

Écueils

• Submit the nail plate, biopsy specimen, and any intervening tissue separately to pathology.
• Consider if nail removal is indicated, or if telescopic biopsy is preferable.

Haneke E. Anatomy of the nail unit and the nail biopsy. Semin Cutan Med Surg. 2015;34(2):95-100ollina U, Nenoff P, Haroske G, Haenssle HA. The diagnosis and treatment of nail disorders. Dtsch Arzteblatt Int. 2016;113(29-30):509-18.Singal A, Bisherwal K. Melanonychia: etiology, diagnosis, and treatment. Indian Dermatol Online J. 2020;11(1):1-11Perrin C, Michiels JF, Boyer J, Ambrosetti D. Melanocytes pattern in the normal nail, with special reference to nail bed melanocytes. Am J Dermatopathol. 2018;40(3):180-1Agner T, Jensen AN, Sachs C. Negleforandringer, 2020. https://www.sundhed.dk/sundhedsfaglig/laegehaandbogen/hud/symptomer-og-tegn/negleforandringer/ (22. jun 2022).Agner T, Jensen AN, Sachs C. Paronychion, 2021. https://www.sundhed.dk/sundhedsfaglig/laegehaandbogen/hud/tilstande-. 11Littleton TW, Murray PM, Baratz ME. Subungual melanoma. Orthop Clin North Am. 2019;50(3):357-366Jellinek N. Nail matrix biopsy of longitudinal melanonychia: diagnostic algorithm including the matrix shave biopsy. J Am Acad Dermatol. 2007;56(5):803-10Moossavi M, Scher RK. Complications of nail surgery: a review of the literature. Dermatol Surg. 2001;27(3):225-8.

Patient history

A 72-year-old man was referred to the department of plastic surgery and breast surgery at Zealands University Hospital, Roskilde, on suspicion of malignant melanoma under the nail of his right thumb.

Examination

The patient presented with hutchinson’s sign, longitudinal melanonychia and no swollen lymphnodes. He had no first-degree relatives with melanoma, no prior history of melanoma (invasive or in situ) and no prior history of other skin cancers.

Pre-operative considerations

Background on Subungual Melanoma (SM)
SM is a rare but serious malignancy arising from the nail matrix. Early diagnosis is crucial for treatment and prognosis. Nail changes are often benign; however, malignancy must always be considered in cases of pigmented nail lesions, particularly longitudinal brown or black streaks (longitudinal melanonychia). Biopsy is required when diagnostic uncertainty persists after clinical and dermoscopic evaluation.

The incidence of SM is not directly associated with ethnicity in terms of increased risk; however, SM accounts for up to 33% of all melanoma cases in individuals with darker skin tones, including African, Latin American, and Asian populations. This reflects the overall lower incidence of cutaneous melanoma in these groups. In Western countries, SM represents approximately 0.7–3.5% of all melanomas.
The highest incidence occurs between 50 and 70 years of age, with equal distribution between men and women. The etiology is often unknown, as ultraviolet radiation is implicated in only approximately 10% of cases.
SM typically originates in the nail matrix and subsequently spreads to the nail plate, presenting as longitudinal melanonychia (LM). Hutchinson’s sign may be observed in more advanced stages, characterized by brown or black pigmentation extending into the periungual skin, which is particularly suggestive of this melanoma subtype. Nail splitting or bleeding from the nail bed may also occur.

Indications for biopsy
• Pigmented longitudinal lesion in the direction of nail growth (melanonychia) with atypical features
• Hutchinson’s sign (pigment lesion in the periungual skin)
• Rapidly growing pigmented nail lesion or nevus
• Suspicion of malignancy following dermoscopic evaluation
• Insufficient diagnostic certainty using non-invasive methods

Differential Diagnoses
Benign conditions:
• Subungual hematoma (trauma-related)
• Onychomycosis (fungal infection)
• Melanocytic hyperplasia (brown, pigmented spots or bands)
• Pyogenic granuloma
• Glomus tumor
• Subungual exostosis
• Myxoid pseudocyst
Malignant conditions:
• Subungual melanoma
• Squamous cell carcinoma (SCC)

ABCDEF Rule for Subungual Melanoma
A – Age: 40–70 years
B – Band: Longitudinal melanonychia > 3 mm; brown/black, broad band with irregular borders
C – Change: Change in size or growth pattern
D – Digit involvement: Most commonly dominant thumb, followed by nondominant thumb, index finger, or great toe; single digit involvement more common than multiple
E – Extension: Extension of pigment into the nail fold (Hutchinson’s sign); ethnicity
F – Family history: Family history or personal history of melanoma

Patient Evaluation
• Document the appearance and width of the pigmented band and the presence or absence of Hutchinson’s sign.
• Perform dermoscopy to evaluate the pigment pattern and exclude benign causes.
otUse ultrasound gel rather than alcohol under the dermatoscope.
• Record relevant history, including trauma, dermatologic conditions, or family history.
• Inform the patient about the risk of nail dystrophy and possible permanent nail loss.
• Ask for local anesthesia without epinephrine.
• Ensure hemostasis using a tourniquet.
• Select the biopsy site at the proximal origin of the pigmentation within the nail fold.
• Consider suturing defects > 3 mm to optimize cosmetic outcome.

Références

Haneke E. Anatomy of the nail unit and the nail biopsy. Semin Cutan Med Surg. 2015;34(2):95-100
ollina U, Nenoff P, Haroske G, Haenssle HA. The diagnosis and treatment of nail disorders. Dtsch Arzteblatt Int. 2016;113(29-30):509-18.
Singal A, Bisherwal K. Melanonychia: etiology, diagnosis, and treatment. Indian Dermatol Online J. 2020;11(1):1-11
Perrin C, Michiels JF, Boyer J, Ambrosetti D. Melanocytes pattern in the normal nail, with special reference to nail bed melanocytes. Am J Dermatopathol. 2018;40(3):180-1
Agner T, Jensen AN, Sachs C. Negleforandringer, 2020. https://www.sundhed.dk/sundhedsfaglig/laegehaandbogen/hud/symptomer-og-tegn/negleforandringer/ (22. jun 2022).
Agner T, Jensen AN, Sachs C. Paronychion, 2021. https://www.sundhed.dk/sundhedsfaglig/laegehaandbogen/hud/tilstande-. 11
Littleton TW, Murray PM, Baratz ME. Subungual melanoma. Orthop Clin North Am. 2019;50(3):357-366
Jellinek N. Nail matrix biopsy of longitudinal melanonychia: diagnostic algorithm including the matrix shave biopsy. J Am Acad Dermatol. 2007;56(5):803-10
Moossavi M, Scher RK. Complications of nail surgery: a review of the literature. Dermatol Surg. 2001;27(3):225-8.