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Melanonychia Clinical Presentation

  • Author: Chris Adigun, MD; Chief Editor: William D James, MD  more...
 
Updated: Apr 26, 2016
 

History

Most melanonychia patients present with a history of asymptomatic hyperpigmentation of the nail plate.

A careful history should include information on medications, past treatments, hobbies, illnesses, family history, any history of trauma to the area, prior history of a biopsy of the nail unit, number of nails affected, results of any prior nail clippings sent for histologic examination, results of cultures sent for infectious organisms, change of appearance of the band (or bands) over time, and ethnic background.[13]

In cases of subungual melanoma, the patient may describe a long-standing history of longitudinal melanonychia that recently changed in appearance. Changes that warrant concern include alteration of color, pattern, or size of the band; new onset of pain or ulceration in the site of longitudinal melanonychia;[14] or the presence of subungual blood.[15]

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Physical

Melanonychia is characterized by a tan, brown, or black discoloration of the nail unit and is often observed in the nail plate. The nail plate may be diffusely involved, or only a single longitudinal band may be present. Transverse melanonychia has also been rarely reported. One or more digits may be involved.

Levit et al identified characteristics of melanonychia that should warrant concern for subungual melanoma, and they used the acronym ABCDEF to describe them, as follows :[16]

  • (A) Age: The peak incidence in the fifth to seventh decade of life. Additionally, subungual melanoma accounts for one third of melanoma cases in Asians, African Americans, and Native Americans.
  • (B) Brown-black band with breadth greater than 3 mm with variegated borders
  • (C) Change in nail band morphology despite treatment
  • (D) Digit involved: The thumb is more likely to be affected by subungual melanoma than the great toe; the great toe is more likely than the index finger to be affected by subungual melanoma.
  • (E) Extension of the brown-black pigment of the nail bed, nail matrix, and/or nail plate onto the adjacent cuticle and proximal and/or lateral nail folds (Hutchinson sign)
  • (F) Family or personal history of dysplastic nevus or melanoma

Careful examination of the oral and genital mucosa may provide important diagnostic clues to identify Peutz-Jeghers syndrome or Laugier-Hunziker syndrome.[17]

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Causes

When determining the etiology of longitudinal melanonychia, it is important to distinguish between melanocytic activation and melanocytic hyperplasia. Melanocytic activation is caused by an increased synthesis of melanin with a normal number of melanocytes. Melanocytic hyperplasia (including melanocytic nevi and melanoma) refers to an increased synthesis of melanin with an increased number of melanocytes. Nevi constitute 12% of longitudinal melanonychia cases in adults and 50% of longitudinal melanonychia cases in children. Note the clinical image below.

Longitudinal melanonychia secondary to a nevus. Longitudinal melanonychia secondary to a nevus.

Approximately two thirds of cases have a brown-black color, and one third of cases have periungual pigmentation (benign pseudo-Hutchinson sign). The bands are wider than 3 mm in greater than 50% of cases.

Below are the causes of melanonychia.[2, 5, 18, 19]

Melanocytic activation/hyperplasia–related causes are as follows:

  • Nevi
  • Melanotic macule of the nail unit
  • Melanocytic activation
  • Subungual melanoma

Physiologic causes of melanonychia are as follows:

  • Racial melanonychia (African American, Hispanic, Indian, Japanese, other dark-skinned races) (multiple bands)
  • Pregnancy (multiple bands)

Local and regional causes of melanonychia are as follows:

  • Trauma (acute or chronic) (single band)
  • Poor-fitting shoes (single band)
  • Onychotillomania (single band)
  • Nail biting (single band)
  • Carpal tunnel syndrome (single band)
  • Foreign body (subungual) (single band)
  • Radiation therapy (multiple bands)
  • Ultraviolet light (multiple bands) [20]
  • Postinflammatory hyperpigmentation (single band)

Systemic causes of melanonychia are as follows:

Dermatologic causes of melanonychia are as follows:

Chemotherapeutic causes of melanonychia are as follows (multiple bands):

  • Bleomycin sulfate
  • Busulfan
  • Cyclophosphamide
  • Dacarbazine
  • Daunorubicin hydrochloride
  • Doxorubicin
  • Etoposide
  • 5-Fluorouracil
  • Hydroxyurea [22]
  • Melphalan hydrochloride
  • Methotrexate
  • Nitrogen mustard
  • Nitrosourea
  • Tegafur

Other drug/agent-related causes of melanonychia are as follows (multiple bands):

  • Corticotropin
  • Amodiaquine
  • Amorolfine
  • Arsenic
  • Chloroquine
  • Clofazimine
  • Clomipramine
  • Cyclines
  • Diquat
  • Fluconazole
  • Fluoride
  • Gold salts
  • Ibuprofen
  • Ketoconazole
  • Lamivudine
  • Mepacrine
  • Mercury
  • Minocycline
  • Melanocyte-stimulating hormone
  • Polychlorinated biphenyl (PCB)
  • Phenytoin
  • Phenothiazine
  • Psoralen [20]
  • Roxithromycin
  • Steroids
  • Sulfonamide
  • Tetracycline
  • Thallium
  • Timolol
  • Zidovudine

Causes of melanonychia associated with a syndrome are as follows:

  • Laugier-Hunziker syndrome (multiple bands)
  • Peutz-Jeghers syndrome (multiple bands)
  • Touraine syndrome (multiple bands)
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Contributor Information and Disclosures
Author

Chris Adigun, MD Nail Expert; Senior Medical Advisor, Klara

Chris Adigun, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, Council for Nail Disorders

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Valeant; Sandos; Cipher; Klara; Miramar<br/>Serve(d) as a speaker or a member of a speakers bureau for: Celgene; Cipher; Klara.

Coauthor(s)

Adam I Rubin, MD Assistant Professor of Dermatology, University of Pennsylvania School of Medicine

Adam I Rubin, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society of Dermatopathology, Women's Dermatologic Society

Disclosure: Nothing to disclose.

Panta Rouhani Schaffer, MD, PhD, MPH Resident Physician, Ronald O Perelman Department of Dermatology, New York University School of Medicine

Panta Rouhani Schaffer, MD, PhD, MPH is a member of the following medical societies: American Medical Association, American Public Health Association

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD Associate Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Richard K Scher, MD Adjunct Professor of Dermatology, University of North Carolina at Chapel Hill School of Medicine; Professor Emeritus of Dermatology, Columbia University College of Physicians and Surgeons

Richard K Scher, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American Medical Association, Association of Military Surgeons of the US, International Society for Dermatologic Surgery, Noah Worcester Dermatological Society, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Anokhi Jambusaria-Pahlajani, MD Resident Physician, Department of Dermatology, University of Pennsylvania School of Medicine

Anokhi Jambusaria-Pahlajani, MD is a member of the following medical societies: American Association of Physicians of Indian Origin and Phi Beta Kappa

Disclosure: Nothing to disclose.

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Longitudinal melanonychia secondary to a nevus.
Pigmented longitudinal streak secondary to a nail matrix melanoma.
 
 
 
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