Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
CROSSMARK LOGO Buy Reprints
PDF

Translate this page into:

Observation Letter
ARTICLE IN PRESS
doi:
10.25259/IJDVL_1292_20

Dermoscopy revealing an amelanotic subungual melanoma masked as contact dermatitis

Department of Dermatology, Melanoma Unit, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
Department of Pathology, Melanoma Unit, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
Corresponding author: Prof. Susana Puig, Department of Dermatology, Hospital Clínic de Barcelona, Carrer de Villarroel, Barcelona, Spain. spuig@clinic.cat / susipuig@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Marti IM, Pigem R, Narvaez MM, Alós L, Puig S. Dermoscopy revealing an amelanotic subungual melanoma masked as contact dermatitis. Indian J Dermatol Venereol Leprol, doi: 10.25259/IJDVL_1292_20.

Sir,

An otherwise healthy 62-year-old woman presented with an acute itchy eruption on her right (dominant hand) middle finger after using a gel nail. There was a history of nail trauma two years back, following which she observed alterations of the nail plate for which she filed her nail regularly. She used an artificial nail for the same reason and developed skin lesions a few days later. Cutaneous examination revealed erythema, desquamation and yellow to red crusts on the finger tip and periungual region along with small vesicles on the dorsum of the middle finger. There was loss of central part of the nail plate [Figure 1]. Dermoscopic examination showed a combination of milky white and pinkish structureless areas (milky-red areas), hemorrhages, patchy white scales, yellow crusts and multiple well-demarcated round/oval yellowish structures (clinically corresponding to small vesicles) [Figure 2]. A real-time herpes simplex virus polymerase chain reaction was negative. Based on the history and examination a clinical diagnosis of contact dermatitis was considered. Topical treatment with betamethasone dipropionate 0.5 mg/g and gentamicin sulfate 1 mg/g cream was prescribed. Patient was followed up to ensure that the dermatitis was responding to therapy and to rule out underlying tumor as a cause of nail plate destruction. Two weeks later, it was observed that though the eczema resolved, the absence of nail plate persisted. On dermoscopic examination, there were helical (corkscrew), polymorphous (helical/corkscrew, looped/hairpin and linear-irregular/serpentine) vessels, milky-red and yellowish-orange structureless areas [Figure 3]. A nail matrix biopsy was performed and revealed the presence of an amelanotic subungual acral lentiginous melanoma [Figure 4]. Regional lymph nodes were normal. Subsequently, the distal phalanx was amputated. An imaging staging with positron emission tomography – computed tomography (PET-CT) scan and a selective sentinel lymph node biopsy performed resulted in a diagnosis of stage IIIB (T2bN2aM0) subungual melanoma according to the eighth edition of the American Joint Committee on Cancer.1

Figure 1:: Erythema, desquamation and yellow to red crusts on the finger tip and periungual region along with small vesicles on the dorsum of the middle finger and absence of central part of the nail plate.
Figure 2:: Polarized dermoscopy examination (×10) of acute eczema of the fingertip at the first medical examination: Milky white and pinkish structureless areas (milky-red areas), hemorrhages, patchy white scales and yellow crusts, well-demarcated round/oval yellowish structures (clinically corresponding to small vesicles)* and absence of the central part of nail plate. *Arrow
Figure 3:: Polarized dermoscopy examination (×10), two weeks later showing helical (corkscrew)*, polymorphous (helical/corkscrew, looped/hairpin and linear-irregular/serpentine) vessels, a combination of milky white and pinkish structureless areas (milky-red) and yellowish-orange structureless areas and absence of the central part of the nail plate. *Circles
Figure 4a:: Spindle-shaped, atypical melanocytic cells proliferation infiltrating the dermis (H and E ×100)
Figure 4b:: Spindle-shaped, atypical melnocytic cells proliferation infiltrating the dermis (H and E x200)
Figure 4c:: SOX10 immunohistochemical staining of the invasive acral melanoma showing strong nuclear positivity (SOX10 ×100)

Subungual melanoma is a rare subtype of melanoma arising within the nail matrix which represents approximately 2% of cutaneous non-sun-induced melanomas in the western world and up to 75% in Africans, 10% in Japanese and 25% in the Chinese.2 No specific figures are available from the Indian subcontinent.2 Almost two out of three subungual melanoma are lentiginous acral melanoma; however, other melanoma variants may be observed.3 Subungual melanoma is often associated with c-KIT mutations, contrasting with other types of melanoma which are linked to BRAF mutations. The mean age of onset is at least ten years later than common melanomas.3,4

Diagnosing subungual melanoma in its early stages is a challenge for dermatologists, which may lead to a late diagnosis resulting in a poor prognosis.4 Subungual melanoma is usually defined as an acquired, broad, triangular melanonychia with the presence of nail plate fissuring and extension of pigmentation to periungual skin (Hutchinson’s sign).2-4 Dermoscopic examination may show a brown band with irregular longitudinal lines of different color and thickness as well as loss of parallelism.4 The presence of a parallel ridge pattern in the hyponychium is an additional clue which increases the suspicion of melanoma. However, between 25% and 33% of subungual melanoma are amelanotic which complicates the diagnosis even further.3 Absence of melanonychia has been associated with longer diagnostic delay in patients with subungual melanoma. Dermoscopic features of amelanotic melanoma are blue-white veil, scar-like depigmentation, multiple blue-gray dots, irregularly shaped depigmentation, irregular brown dots/globules, five–six colors and predominant central vessels.5 Guidelines giving specific dermoscopic clues for amelanotic subungual melanoma are lacking. Dermoscopic features of normal nail include a non-pigmented nail bed and plate and a nail fold with a homogeneous capillary (hairpin-shaped vessels) distribution without morphological atypia.6 In the present case, features like corkscrew and polymorphous vessels together with milky-red areas, which are diagnostic of amelanotic melanoma at other locations, led to suspecting the diagnosis.5Although these findings are not seen frequently, but when present, they are highly suggestive of melanoma.7 Milky-red areas correlate with a positive predictive value of 77.8%.7 However, they can also be seen in basal cell carcinoma, Spitz nevus, pyogenic granuloma and even in inflammatory lesions. Cutaneous melanoma metastasis and non-melanoma skin cancer should be considered in the differential diagnosis of polymorphous and corkscrew vessels.7 In our opinion and experience, dermoscopic features described in amelanotic melanoma at other locations are noted to be present in amelanotic subungual melanoma also. However, more reports are necessary to substantiate this finding. Dermoscopic examination is of utmost importance in diagnosing early stages of subungual melanoma.

Onychomycosis, trauma, subungual hematoma, onychodystrophy and pyogenic granuloma are other differentials that can cause delay in the diagnosis and worsening of the prognosis. In the present case, the patient consulted for a contact dermatitis which masked the subjacent subungual melanoma hidden by the use of artificial nails. In recent years, there has been an increase in the use of artificial nails resulting in a higher incidence of contact dermatitis.8

In conclusion, subungual melanoma is a diagnostic challenge with crucial prognostic implications. A considerable proportion of cases are amelanotic which makes the diagnosis even more difficult. Dermoscopic examination, showing polymorphic and irregular vessels, may be extremely helpful. Contact dermatitis mask its presentation, particularly in users of artificial nails and it is of vital importance to make the general population aware that any destruction of the nail plate should be evaluated by a dermatologist before covering it with an artificial nail.

Declaration of patient consent

The patient's consent is not required as the patient's identity is not disclosed or compromised.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. , , , , , . Melanoma of the skin In: , , , , , , eds. AJCC Cancer Staging Manual (8th ed). Switzerland: Springer; . p. 563-85.
    [Google Scholar]
  2. , , , . Subungual melanoma is not so rare: Report of four cases from India. Indian Dermatol Online J. 2017;8:471-4.
    [CrossRef] [Google Scholar]
  3. , , , . Missed opportunity to diagnose subungual melanoma: Potential pitfalls! BMJ Case Rep 1-6.
    [CrossRef] [Google Scholar]
  4. , , , , , . Dermatologists' accuracy in early diagnosis of melanoma of the nail matrix. Arch Dermatol. 2010;146:382-7.
    [CrossRef] [Google Scholar]
  5. , , , , , , et al. Dermoscopic evaluation of amelanotic and hypomelanotic melanoma. Arch Dermatol. 2008;144:1120-7.
    [CrossRef] [Google Scholar]
  6. , , , . Onychoscopy. Clin Dermatol. 2013;31:587-93.
    [CrossRef] [Google Scholar]
  7. , , , , , , et al. Vascular structures in skin tumors: A dermoscopy study. Arch Dermatol. 2004;140:1485-9.
    [CrossRef] [Google Scholar]
  8. , , . Allergic contact dermatitis caused by acrylates and methacrylates-a 7-year study. Contact Dermatitis. 2014;71:102-7.
    [CrossRef] [Google Scholar]

Fulltext Views
1,368

PDF downloads
40
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections