Nail matrix biopsy of longitudinal melanonychia: Diagnostic algorithm including the matrix shave biopsy

doi:10.1016/j.jaad.2006.12.001

Journal of the American Academy of Dermatology

Volume 56, Issue 5, May 2007, Pages 803-810

https://doi.org/10.1016/j.jaad.2006.12.001 Get rights and content

Longitudinal melanonychia (LM) may represent nail matrix melanocyte activation (defined as a normal number of melanocytes with increased production of melanin), benign hyperplasia, or melanoma, in addition to multiple nonmelanocyte pathologies, including hemorrhage and infection. This article details an algorithmic approach to LM, including a careful history and physical examination, dermoscopy, and ability to sample the matrix using 3 biopsy techniques, a 3-mm punch excision, a lateral longitudinal excision, and a matrix shave biopsy. Facility with all 3 techniques will allow the physician to procure appropriate nail matrix specimens for diagnosis.

Section snippets

Shave biopsy of the nail matrix^1,11,12,32

Once adequate anesthesia is achieved, careful attention is paid to the proximal nail fold and cuticle. If either or both of these anatomic units demonstrate pigmentation (as a pseudo-Hutchinson's sign or true Hutchinson's sign, the clarification of which is determined by histopathology),³³ a shave biopsy of the sliver of pigmented tissue can be performed and the tissue placed in a formalin jar as the first specimen. Tangential incisions are made at the junction of the proximal and lateral

Discussion

Biopsy of the nail unit for LM requires adequate sampling of the nail matrix, a site normally protected by both the nail plate and overlying proximal nailfold. Optimally, an excisional biopsy is performed, with the choice of a technique that results in minimal or no permanent dystrophy. Traditional techniques include punch biopsy, which is one accepted and widely used technique for LM less than 3 mm in width originating in the distal matrix, and lateral longitudinal excisions for lateral

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Both dermatologists and pathologists sometimes find daunting the evaluation of melanonychia (especially subungual melanocytic lesions) because of the fear of performing nail surgery due to the risk of dystrophy, difficulties processing and interpreting nail biopsy specimens, and a general lack of experience in the field. Nevertheless, mastery of nail biopsy techniques, correct processing and orientation of specimens, and familiarity with the histologic particularities of the nail apparatus can attenuate the undoubted complexity and facilitate the tasks involved. Longitudinal excision is the biopsy technique that ensures the simplest histologic interpretation, and it is associated with a low risk of nail dystrophy when performed correctly. Clinical and epidemiological data are crucial. Subungual melanoma in childhood, for instance, is very rare and even lesions with atypical clinical and/or histologic features are probably benign. The presence of suprabasal melanocytes and other findings that would suggest malignancy at other sites are considered normal in the nail apparatus. Subungual melanoma shows a lentiginous pattern in the early stages of disease, and detection of an inflammatory infiltrate accompanying atypical lentiginous subungual lesions would appear to be one of the first diagnostic findings.
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Funding sources: None.

Conflict of interest: None declared.

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Dermatologic SurgeryNail matrix biopsy of longitudinal melanonychia: Diagnostic algorithm including the matrix shave biopsy

Section snippets

Shave biopsy of the nail matrix1,11,12,32

Discussion

J Am Acad Dermatol

J Am Acad Dermatol

Adv Dermatol

J Am Acad Dermatol

J Am Acad Dermatol

J Am Acad Dermatol

J Am Acad Dermatol

J Am Acad Dermatol

J Am Acad Dermatol

J Am Acad Dermatol

Hand Clin

Nail surgery and traumatic abnormalities

Nail biopsy. Indications and methods

J Dermatol Surg Oncol

Quantification of regional matrix nail production

Br J Dermatol

Keratin expression in the normal nail unit: markers of regional differentiation

Br J Dermatol

Longitudinal melanonychia

Lateral longitudinal nail biopsy

Australas J Dermatol

Nail biopsy: indications and methods

Dermatol Surg

Acquired malalignment: a complication of lateral longitudinal nail biopsy

Acta Derm Venereol

Complications of nail surgery: a review of the literature

Dermatol Surg

Biopsy techniques

Longitudinal melanonychia

Dermatol Surg

Early malignant melanoma manifested as longitudinal melanonychia: subungual melanoma may arise from suprabasal melanocytes

Br J Dermatol

Dermatologic Surgery
Nail matrix biopsy of longitudinal melanonychia: Diagnostic algorithm including the matrix shave biopsy

Shave biopsy of the nail matrix^1,11,12,32