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
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:

Quiz
87 (
1
); 127-130
doi:
10.4103/ijdvl.IJDVL_772_18
pmid:
31389378

The case of a bleeding nail

Departments of Dermatology and STD, University College of Medical Sciences and GTB Hospital, Delhi, India
Department of Pathology, University College of Medical Sciences and GTB Hospital, Delhi, India
Corresponding author: Prof. Chander Grover, Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, Dilshad Garden, Delhi - 110 095, India. chandergroverkubba76@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: Grover C, Chauhan A, Sharma S. The case of a bleeding nail. Indian J Dermatol Venereol Leprol 2021;87:127-30.

The Case

A 45-year-old farmer presented with thickening and discoloration of medial half of left thumbnail, which was slowly progressing over 2 years. He found it increasingly difficult to cut this hard and compact nail, even having to use a blade at times. On cutting, he noticed small bleeding points which dried to form blackish crusts.

On examination, there was a medial stump of the left thumbnail with yellowish discoloration and blackening. Distally, there was a compact subungual hyperkeratosis with blackish debris deposited [Figure 1].

Figure 1a:: The frontal view of the left thumbnail showing the thickened, discolored, and partially cut off nail plate. Note the distal-free end of the nail plate and the yellowish discoloration seen dorsally, which has a sharp demarcation from the normal nail plate

Onychoscopy showed the presence of linear yellowish-brownish streaks running the length of the nail-plate stump with small discolored cavities, containing debris visualized distally [Figure 2]. Direct microscopy and fungal culture were negative. Radiograph showed no bony involvement. A magnetic resonance imaging (MRI) could not be done due to resource constraints.

Figure 2a:: Dermatoscopic examination (onychoscopy): Dorsal view showing longitudinal parallel white lines (black arrows) along with an occasional splinter hemorrhage (red arrow), running through the stump of the nail-plate (AM4115MZT; ×150, polarizing view with linkage fluid)
Figure 2b:: Dermatoscopic examination (onychoscopy): Examination of the distal end showing thickening of the nail plate with multiple whitish channels/ cavities (keratinized) (black arrows) with dark dots (blue arrow) (Dino-Lite AM4115MZT; ×150, polarizing view with linkage fluid)

Partial avulsion of the affected nail plate revealed an underlying, “anemone-like” villous mass with small cavities in the proximal end of removed nail plate [Figure 3]. Both the nail plate and excised villous mass were examined histopathologically [Figure 4]. Histopathology revealed a thickened perforated nail plate apparently having multiple cavities. The villous mass was seen as a matrical tumor with multiple surface digitations and matrix epithelium lining. The underlying collagenous stroma was more cellular with fibrillary collagen superficially and dense, less cellular collagen in the deeper part of the tumor.

Figure 3a:: Lateral partial avulsion of the affected nail plate. The avulsed stump shows an ireegular and grossly thick proximal margin
Figure 3b:: The filiform mass (arrow head) arising from underneath the proximal nailfold can be seen after removal of nail plate
Figure 4a:: Histopathological examination shows a thickened nail plate perforated by multiple cavities filled with serous contents (H and E, ×100)
Figure 4b:: Histopathological examination shows matrical tumor with multiple digitations on the surface, lined with matrix epithelium. The underlying collagenous stroma is more cellular with fibrillary collagen, superficially; while there is less cellularity and dense collagen in the deeper part of the tumor (H and E, ×100)

What Is Your Diagnosis?

Diagnosis

Onychomatricoma (onychomatrixoma).

Discussion

Onychomatricoma is a rare tumor arising from the nail matrix. It was first described in 1992.1 Subsequent to standardization of its terminology in 1995, only a few hundred cases have been described till now in literature, as it is probably less recognized by dermatologists and pathologists alike. The filamentous matrix tumor predominantly affects fingernails, growing distally as longitudinal channels within the nail plate. Studies show that it arises commonly in middle-aged women in the fifth decade, although other reports have shown no such sex predilection.2 The diagnosis is often delayed due to the slow growth of the tumor and the absence of pain. Many of these cases are misdiagnosed as onychomycosis and treated for long periods.

Clinically, onychomatricoma is mostly asymptomatic, but is characterized by the diagnostic tetrad of xanthonychia, longitudinal overcurvature, multiple splinter hemorrhages, and longitudinal ridging.3 The distal nail plate may show “woodworm”-like holes. Other diagnostic procedures include dermatoscopy of nail (onychoscopy), radiological imaging, and histopathology.

Onychoscopy shows the presence of perforations in the distal part of the nail plate (woodworm-like cavities), hemorrhagic striae and whitish longitudinal grooves within the nail plate (suggestive of tumor channels), and proximal and distal splinter hemorrhages.2 Plain skiagrams are generally normal, but ultrasonography can show the presence of hypoechoic tumoral lesion in the nail matrix with hyperechogenicity in the nail plate (corresponding to finger-like projections). MRI shows the characteristic invasive morphology of the tumor and is considered diagnostic.4

The excised tumor shows fibroepithelial morphology with two distinct zones: a proximal zone with deep matrix epithelial invaginations along with overlying ungual projections and the distal zone showing epithelial digitations originating from the matrix and perforating the nail plate.5 Such matrix proliferations correlate with the whitish longitudinal grooves within the nail plate, as seen on onychoscopy. These very same matricial projections with dried up blood present as the distally visible “woodworm cavities.” The tumor is both CD10 (a marker of onychodermis) and CD34 (expressed by dendritic or fibroepithelial-like mesenchymal cells) positive.3 A rare pigmented variant has also been described.6

The differential diagnoses include onychoblastoma,3 fibrokeratoma,4 periungual fibroma, subungual verruca vulgaris,3 and even squamous cell carcinoma. In longitudinal sections, the histopathology of onychomatricoma may be reminiscent of ungual fibrokeratomas; however, a fibrokeratoma lacks the multiple fibroepithelial projections and nail plate perforations characteristic of the onychomatricoma.4 Another distinguishing feature is the lack of the hyperplastic onychomatricial epithelium in the layer. These features also suggest that onychomatricoma may have a malignant potential, not hitherto known.7

The treatment for onychomatricoma is complete surgical excision. This requires the partial avulsion of the affected nail plate to visualize the underlying matrix growth which needs to be excised completely. Inclusion of some normal nail matrix proximal to the lesion is advised to help prevent local recurrences, even though the occurrence is rare. Subsequent nail scarring is dependent on the extent of the tumor and the extent of the growth. Very few long-term studies are available and mostly no recurrence has been reported. However, one should be aware of the continuum with potentially malignant onychomatricoma existing.7

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. , . Onychomatrixoma, Filamentous tufted tumour in the matrix of a funnel-shaped nail: A new entity (report of three cases) Br J Dermatol. 1992;126:510-5.
    [CrossRef] [PubMed] [Google Scholar]
  2. , , , , , , et al. Onychomatricoma: Epidemiological and clinical findings in a large series of 30 cases. Br J Dermatol. 2015;173:1305-7.
    [CrossRef] [PubMed] [Google Scholar]
  3. , , , , . Onychomatricoma: A rare tumor of nail matrix. Ann Dermatol. 2016;28:237-41.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , . Onychomatricoma: A tumor unknown to dermatologists. An Bras Dermatol. 2015;90:265-7.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , , , . The onychomatricoma: Additional histologic criteria and immunohistochemical study. Am J Dermatopathol. 2002;24:199-203.
    [CrossRef] [PubMed] [Google Scholar]
  6. , , , , . Pigmented onychomatricoma: A rare pigmented nail unit tumor presenting as longitudinal melanonychia that has potential for misdiagnosis as melanoma. J Foot Ankle Surg. 2015;54:723-5.
    [CrossRef] [PubMed] [Google Scholar]
  7. , . Onychomatricoma: Benign sporadic nail lesion or much more? Dermatol Online J. 2006;12:4.
    [Google Scholar]
Show Sections