Tuesday, May 20, 2014

Median Nail Dystrophy

Patient 1: A 65 yo woman with a 3 month history of a medial split in the right thumb nail. It is asymptomatic. No history of trauma. The physical exam showed the split begins at the proximal nail fold. There is a suggestion of erythema at its proximal end.

Patient 2: A 79 yo woman with a 3-6 months history of a medial split in the right thumb nail. It is painful with pressure otherwise asymptomatic. No history of trauma. The physical exam reveals the same finding as the patient 1 without a suggestion of erythema at the proximal fold. 

Clinical Images:  

Patient 1: Clinical View
Patient 1: Dermoscopic View
Patient 2: Clinical View
Patient 2: Dermoscopic View

Diagnosis: Median nail dystrophy.  Is this secondary to a subungual tumor? Is a biopsy indicated?


Glomus tumor-induced longitudinal splitting of nail mimicking median canaliform dystrophy. Verma SB. Indian J Dermatol Venereol Leprol. 2008 May-Jun;74(3):257-9.
Abstract:Median canaliform deformity of the nail is an uncommon entity, where there is longitudinal splitting of the nail. Longitudinal splitting of the nail is a rare phenomenon and can also occur following number of growths arising in the nail matrix. On examination there was a longitudinal split in the nail plate, beginning in the distal nail fold and extending proximally all the way to the proximal nail fold. There was a small, almost indiscernible, swelling in that area, which was exquisitely tender. The split part of the nail showed a little discoloration. There was no discharge, bleeding, or subungual mass visible. 'Love test' was positive in this case. After nail avulsion, a small 2 mm x 4 mm nodule was exposed and excised. Histopathological examination of the tumor showed a mantle of glomus cells surrounding the blood vessels.  Free Full Text.

1 comment:

  1. comment of Dr. Eckart Haneke: Thank you veery much for your mail and the ingteresting cases. Both are typical for Heller's median canaliform thumb nail dystrophy.
    When you look at the nails as a whole you will notice that the nails are disproportionagtely long for thumbs - a sign that there is a repeted (minor) trauma. I do not see an indication for a nail matrix biopsy as there is no specific alteration known.
    I tell my patients that they have to very gently massage the proximal nail fold and nail - always this direction! - with an ointment. I prefer azelaic acid because it was mentioned in the beginning of the azelaic acid history that it has a positive effect on nail growth (never substantiated, however). Almost all patients deny the habit tic of pushing back the cuticle and proximal nail fold, but this is part of the condition.
    If the patients cannot stop their habit give them acetyl cysteine, 3x600 mg a day. This is an anti-obsessive anticompulsive drug without an psychotropic action.


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