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?

Reference:

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.

Median Nail Dystrophy

The patient is 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.

O/E:  The split begins at the proximal nail fold.  There is a suggestion of erythema at its proximal end.

Clinical Images:  Courtesy of Yoon Cohen

Diagnosis: Median nail Dystrophy.  Is this secondary to a subungual tumor?

Reference:

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.

Two Patients with Longitudinal Nail Dystrophy

This past month, I saw two patients with median nail dystrophies. This is an area that has only rarely been written about. These patients are presented for your interest and thoughts. If you experience difficult with the comment function, you can email DJ Elpern with your thoughts.

Case 1.
55 yo man with a 1-2 year history of a linear striation of the left thumbnail. This is painful with pressure and occasionally spontaneously painful. There is a three mm in diameter pink striation in the left thumbnail beginning at the proximal nail fold. The distal portion of the nail is somewhat deformed and there is the suggestion of an erythematous subungual papule.

Diagnosis: Possible Subungual tumor. I am considering glomangioma. (See below for follow-up)
Questions: Would the best approach be to avulse the entire nail and then do a small elipse? What else would you do here?
Follow-up: The patient first saw a hand surgeon who recommended amputation of the distal portion of the digit. Scared, he saw a second hand surgeon who said he thought this was a glomus tumor and excised it. Pathology confirmed the diagnosis of Glomus Tumor. This photo was taken approximately two months post-surgery.

18 mo post surgery

24 mo post surgery

Case 2.
60 yo woman with 3 month history of an asymptomatic longitudinal split on the left thumbnail. No history of trauma.

Diagnosis: I favor median nail canal (dystrophia unguis mediana canaliformis) here, although at first was concerned about a subungual tumor.
Question: Would you observe or explore and biopsy? Has anyone had success treating this entity?
Follow-up: This lesion was excised by an orthopedic surgeon in November of 2011. It was a Glomus tumor.

Comment: Until I prepared these cases for presentation the diagnoses were less clear to me (perhaps I am wrong anyways). Getting them ready for VGRD-Blog was a good educational exercise. Joubert wrote: "To teach is to learn twice."

Nail References:
Verma SB. Glomus tumor-induced longitudinal splitting of nail mimicking median canaliform dystrophy. Indian J Dermatol Venereol Leprol. 2008 May-Jun;74(3):257-9. (Free Full Text)
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.

Unusual Nail Bed Tumor

Abstract: 67 yo man with 1 - 2 month hx of a nail bed tumor.

HPI: 67 yo man with 1 - 2 month hx of a nail bed tumor. The overlying nail has been destroyed. Lesion is asymptomatic.

O/E: 8 mm diameter flesh-colored tumor left thumb nail. No pigment. Lesion is solid, not friable.

Clinical Photos


Pathology: Hyperkeratosis, parakeratosis, epidermal hyperplasis. There are ectatic blood vessels in an edematous and fibrotic stroma. Iin the DDx is an unusual traumatized hemangioma or subungual fibroma.

Microscopic Photos courtesy of Deon Wolpowitz, Boston University SkinPath





Diagnosis: Benign nail bed tumor, not otherwise specified. Presented for ideas.

Questions: What is your diagnosis, and how would you approach this lesion?

Plan: The patient has been referred for defintive surgery to a Mohs surgeon.