Case discussion: How would you treat this patient? [24 July]

This week we have a great case from Dr. Mel Cabatuando. This middle-aged, male patient had only recently noticed this pigment under his thumb nail. This is a common problem.

  1. How do you differentiate between haematoma and melanoma in this setting?
  2. What are the key features of each, and how do you manage these patients?

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Case submitted by Dr. Mel Cabatuando

Please share your thoughts in the comment section below. Professor David Wilkinson will provide his opinion and advice.


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8 comments on “Case discussion: How would you treat this patient? [24 July]

  1. History of trauma and duration of the lesion is important. If a haematoma the colour is more uniform. Use a dermatoscope to see if there is a pigment pattern which will be the case in a melanoma.

  2. subungual melanoma usually arises from the nail matrix under the lunula.
    I would expect to see melanonychia. A streak of melanin pigmentation extending from the base of the nail, possibly with pigmentation involving the cuticle as well, Hutchinson’s sign. In the case of melanoma some elongated chaotic pattern to the Melanonychia. There are other non malignant potential causes of similar nail pigmentation; naevi, racial pigmentation and drug effects.
    In this case, it looks like a haematoma. The pigmentation doesn’t start from the matrix, the pigmentation is darker proximally and it spreads out distally, suggesting the proximal region is the source of the blood. A growing lesion such as a melanoma would expected to produce a melanonychia slightly broader proximally.
    Its not uncommon for the patient to not be aware of a specific traumatic event.

  3. A triangular blue lesion in the peripheral nails looks to be trauma related. Just FP and watch it as it will go with growth to the edge,

  4. I would review patient in 14 days after taking dermoscopical image for better assessment of movement towards the edge, melanonychia or not need follow up, I had case with melanonychia and experts at Peter Mac Melbourne cancer centre observed over time without biopsy for few months. (later melanonychia faded away) This looks more like trauma, but I would like to see photo under dermoscope.

  5. for Q1: How do you differentiate between haematoma and melanoma in this setting?> +/- of trauma and duration. Agree with David Smith unawareness of trauma hx is not uncommon at times.

    for Q2: What are the key features of each, and how do you manage these patients? as per all of you. Review in 2-3/52 will be much helpful where haematoma will resolve / regress to a degree.

    My honest question to all of you is: what method of biopsy would you chose if suspicion of melanoma? I wonder punched biopsy in order to include both nail matrix and underneath tissue or other which would like add and share!!

    Regards 🙂

  6. Hi Tim,
    Like anything else there are examples that are difficult to differentiate, but more often with a melanonychia, which this case doesn’t demonstrate.
    The feature of the melanonychia caused by melanoma is the streaked variation in colour, and even some chaotic pattern to the streaks. The potential melanoma demands biopsy. The biopsy requires a specimen from the matrix which will probably result in a permanent nail deformity so not something to be taken lightly. A haematoma will resolve but this takes months rather than weeks. It would be unlikely to have changed in 2-3 weeks. You probably need to have a look at some photos in the texts for the features of both.
    Cliff Rosenthaul has a biopsy method called “flipping the lid” ( there is a video going around that maybe healthcert could make available) that is relatively simple and elegant. Its very important to get it right and get a useful specimen. If you are uncertain I’d refer the patient for the biopsy.

  7. The range of differentials together with the history are quite clear. I agree with suggestion made so far. For a non-trauma lesion of this kind how long are you going to observe. I kept asking myself the best biopsy option? What would it be?