Abstract
Nail matrix melanoma, otherwise known as subungual melanoma, is unique in that the actual primary cutaneous melanoma is occult, being covered by the nail plate and the proximal nail fold. Fortunately, the concealed melanoma may produce melanin, which then appears as longitudinal pigmentation in the nail plate. Thus melanin-producing nail matrix melanoma has a distinctive ‘signature’ to the informed observer. Acral lentiginous melanoma was first described as a subgroup in 1976 by Reed [1]. Prior to that Clark had proposed three histologic sub-types: superficial spreading melanoma, lentigo maligna melanoma and nodular melanoma [2]. About half of all hand and foot melanomas are of the acral lentiginous subtype. A Scottish study restricted to subungual melanoma showed that 45% were acral lentiginous, 27% nodular and 20% superficial spreading in type [3]. We present two consecutive cases of nail matrix melanoma from a general practice. The first patient was referred to the practice and the second patient was recommended to the practice by the first.
Highlights
Nail matrix melanoma, otherwise known as subungual melanoma, is unique in that the actual primary cutaneous melanoma is occult, being covered by the nail plate and the proximal nail fold
A Scottish study restricted to subungual melanoma showed that 45% were acral lentiginous, 27% nodular and 20% superficial spreading in type [3]
Subungual melanomas were evenly distributed between hand and foot, but hallux and thumbnails were disproportionately affected compared to other digits and there was equal incidence of nail subungual melanoma across all races
Summary
Otherwise known as subungual melanoma, is unique in that the actual primary cutaneous melanoma is occult, being covered by the nail plate and the proximal nail fold. A 25-year-old high school science teacher was referred with a lesion on his right thumbnail (Figure 1A), arriving by a circuitous route One of his teenage students had seen a photograph of a nail melanoma on a patient education poster in the waiting room of a doctor’s surgery office and thought the photo looked like her teacher’s thumb. A provisional diagnosis of nail matrix melanoma was supported by both the history of a new and progressively widening nail plate pigmentation and the dermatoscopy showing lines parallel of varying thickness interval and colour. The circular plug of nail plate was lifted out to reveal a densely pigmented lesion in the underlying nail matrix (Figure 3) This was circumscribed with a 4 mm biopsy punch and dissected from underlying periosteum with a scalpel blade. The patient was referred to a plastic surgeon for definitive treatment of a level 1 nail matrix melanoma
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