Tuesday, July 03, 2018

Renal Transplant Patient with a Black Toe

The patient is a 70 yo man who had a renal transplant around 10 years ago.  His immunosuppression consists of oral tacrolimus and prednisone, and he is seen annually by a dermatologist.  He had a 3 cm superficial squamous cell carcinoma ofhis scalp 5 years ago that was treated successfully with topical 5FU.

O/E: The current exam revealed a black area under the nail of the second toe on the left foot.  He said it's been like his for around a year and has not changed much.

Clinical and Dermatoscopic Images:
Diagnosis and Discussion:
While I am pretty certain that this is a subungual hematoma; if his history is accurate that may be worrisome.  There is little downside to removing the nail and biopsying the nail base if it is pigmented and this was scheduled in a week's time.  The fact that this is Morton's toe also favors subungual hematoma.


  1. from Patrick Kenny, Voctoria, BC: To me also subungal hemorrhage is the likley answer . What I do is measure distance from proximal part of discolouration to proximal nail fold , and review after two months , and can then demonstrate to patient how the discolouration has moved forward free end of nail . A photograph on smart phone works well .

  2. from Dr. Cheng Leng, Malaysia: I agree with you most probably it’s Subungal hematoma. Its history is a bit long but we have seen splinter haemorrhage hanging around for long time too.

    In view of his ten years of immunosuppression, the other possibility is pseudomonas nail infection, which usually gives a green or bluish discolouration. Getting the right chemical mix, it may turn dark? But I haven’t seen it this dark, has anyone else?

    His great toe, the affected second toe and the last toe also show nail changes suggesting onychomycosis. Nail scraping for microscopy is necessary. I usually shy away from Fungal nail culture as it may bring in many distant microbe relatives, with unfamiliar names, many being contaminants. Fungal infection may have paved the way for pseudomonas secondary infection.

    If patient is worried about melanoma, we may be pushed to rush things a bit. Otherwise may be better to treat the infections first before biopsy? I find pushing up gentamicin ointment ( you can use eye ointment if you can’t get skin ointment) under the nail helpful.

  3. I think its a sublingual hematoma too and she is probably getting repeated trauma to the nail due to the length of her toe and also the thickening of the nail. Could you treat her with weekly diflucan 200 mg also to see if she gets some response after 3 months.
    Then if the pigmentation has not moved distally due a nail biopsy if you are still concerned about melanoma.


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