Case discussion: How would you treat this patient? [26 June]

This week we have an engaging case discussion from Dr Atmaram Rana. A 54-year-old female presented for a skin check, and this was noted.

What is your differential diagnosis and what would you do?

Case submission - Atmaram Rana     Case submission - Atmaram Rana

Case submission - Atmaram Rana

Case submitted by Dr Atmaram Rana

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

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13 comments on “Case discussion: How would you treat this patient? [26 June]

  1. there are no features of melanonychia longitudinalis striata, this is either onychomatrixoma early stages or foreign body embedded

  2. its a splinter hemorrhage due to underlying mass under the nail. Could be onychopapilloma.

  3. other DD can be erythronychia would imply the cause can lie between Mimicking glomus tumor, SCC, Bowen disease, nail bed lichen planus, amyloidosis & Darier’s disease.

  4. For this single band of dark-brown melanonychia-
    first thought, splinter (FB) as started from distal. However it was not linear/continuous, and it has some interrupted streaks of dark-brown > possible melanocytes proliferation from nail matrix. If looked into carefully by zooming, there is ?network especially in the 2nd segment (count from distal). Thus serious attention is required given age (4th decade onwards), + if no prior Hx of trauma and secondary systemic disorders.
    D/Dx: 1/ Benign naevus/lentigenous of nail; 2/ MM-insitu; 3/ Trauma (FB); 4/ nail pigmentation secondary to systemic pathology or drug induced.
    Techniques of biopsy would be very important .

    Feedback- at times better have a zoom picture of dermatoscope.

  5. Not everything is a skin cancer! This is (I think) onychopapilloma. What would you do with it? Biopsy? yes/no? How? Treatment?

    1. HI Everyone, to update on this case.
      1. There is no history of trauma.
      2. This lesion has been stable for 4-5 years and she is not worried and asymptomatic.
      3. On the Normal view: Right thumb: has distal linear black line(not continuous) that accompanies longitudinal ridge that starts from proximal nail folds with distortion of the lunula and distally you can see Leuconychia. You can also see similar lesion if you look closely on the left thumb without the distal black line but with longitudinal ridge and distal leuconychia.
      4. On the Free Edge Dermoscopy: you can see subungual keratotic mass with the black line on top of it. Sorry for the poor picture(tried to pull the mass down but couldn’t), clinically the black line is not on the nails seen from the undersurface of the nail free edge and the keratotic mass can be moved easily. So the black line is actually splinter haemorrhages on top of the mass.

      My initial thought: it was likely Onychopapilloma with multiple other Ddx including malignancy. Since its stable and asymptomatic , i didn’t want to put my patient through pain of biopsy and further nail dystrophy. Academically definite answer would have been wonderful. i don’t know if we can get some answers through distal nails clipping that would include both the distal nail and some keratotic mass. For the time being, i’m only monitoring her unless there is any other significant points from you all.

      Thank you prof. wilkinson and all other participants for your insights. I’ll try to take better magnification picture and also with gel interface non-polarised view next time.

  6. For the biopsy, we should do nail extraction and curettage of all the hyperkeratotic lesions on the nail bed and be sent for histology to distinct any malignant growth if in doubt. The surgical treatment to remove the hyperkeratotic tumor mass by curettage can be one of the acceptable methods for improving the patient’s symptom for sure.

  7. There is distal subungual hyperkeratosis, early triangular onycholysis, splinter hemorrhage. The lesion is starting from Matrix. There is distortion of lunula in compare with other side. The image is not ideal but I think there is polychromia. DD bowen’s disease, onychomatricoma or onychopapiloma. More likely to be bowen’s disease as the edge of involved area is not sharply demarcated as usually seen in onychomatricoma. Needs biopsy which should include matrix.

  8. Tx options for papilloma:
    1/ Cryotherapy (given small lesion) every 2 week x 2 or 3 sessions
    2/ lastly excision.
    Is there any others???