Caleb Foster
Melanoma is a type of skin cancer that usually starts in the epidermis, the top layer of skin. However, it can also develop under the nail plate, known as subungual melanoma. Subungual melanoma is an uncommon form of melanoma, accounting for about 3% of cases, and it can affect the toenails or fingernails. It typically presents as a brown or black discolouration of the nail bed, which may appear as a narrow band or an irregular area of pigmentation. While the exact cause of subungual melanoma is unknown, it is believed to be unrelated to sun exposure, and certain factors such as age, ethnicity, and personal/family history of melanoma may increase the risk of developing this condition. Diagnosis of subungual melanoma involves a thorough patient history, physical examination, and investigations such as dermoscopy and biopsies. Treatment options include surgery, immunotherapy, and radiation, with early detection being crucial for successful outcomes.
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What You'll Learn
Subungual melanoma symptoms
Subungual melanoma, also known as nail unit melanoma, is a rare type of skin cancer that develops under the nails. It occurs in the nail matrix, which is located at the base of the nail and is responsible for producing keratin. It is a subtype of cutaneous malignant melanoma that arises from structures within the nail apparatus. Unlike other skin cancers, it is not linked to sun exposure.
Subungual melanoma can affect any area of the skin, but it most commonly affects the thumb and the big toe. It can also occur in any of the other fingernails and toenails. It usually starts as a narrow brown to black pigmented band, visible on the length of a single nail plate (melanonychia). Over time, the pigment band becomes wider (greater than 3 mm), especially at its proximal end (cuticle), and more irregular in pigmentation (light and dark brown). It may also extend to involve the skin of the proximal or lateral nail fold (periungual pigmentation), also known as the "Hutchinson sign".
The most common symptom of subungual melanoma is a discolored line that appears on the nail. It is usually brown or black and runs from top to bottom (vertical). In some cases, the line can be irregularly shaped and increase in length and width over time. Other symptoms include:
- Nail separation from the nail bed
- Nail splitting, cracking, or deformation
- Irregular pigmentation (the discoloration isn’t even)
- Swelling or inflammation
- Bleeding
- Pain at the nail bed
It is important to note that the early signs of subungual melanoma can be easy to miss as they occur underneath the nails. Therefore, if you notice any of the above symptoms or any other changes in your nails, you should promptly consult a trained medical provider. A healthcare provider will examine your nail and review your medical history to determine if your nail area looks like subungual melanoma and if you are at high risk for the condition. Diagnosing subungual melanoma typically involves performing a dermoscopy or a biopsy of the nail bed to examine the nail more closely and determine whether the cells are cancerous.
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Diagnosis of nail melanoma
Subungual melanoma, also known as nail unit melanoma, is a type of skin cancer that develops under the nails. It is a subtype of cutaneous malignant melanoma that arises from structures within the nail apparatus. It occurs in the nail matrix, which is located at the base of the nail and is responsible for producing keratin.
Nail melanoma most often affects the great toe and thumbnail, accounting for 75-90% of cases. However, any nail on the finger or toe may be involved. It is a rare form of melanoma, accounting for only 0.7-3.5% of all melanoma cases worldwide. It is the most common type of melanoma diagnosed in deeply pigmented individuals and among African-American, Asian, and Hispanic people.
The diagnosis of nail melanoma can be challenging due to its similarity to other pigmented nail disorders in the early stages. The main challenge is obtaining adequate nail matrix biopsy specimens for histopathological assessment. The histopathologic examination is considered the gold standard for diagnosing nail melanoma. A biopsy of the nail matrix and nail bed is required for a definitive diagnosis. The biopsy involves collecting a tissue sample from the affected nail, which is then examined by a pathologist to determine if the cells are cancerous.
Before performing a biopsy, a physician will typically begin by asking questions about the patient's symptoms and medical history. A physical examination of the fingernail or toenail will also be conducted. Dermoscopy may also be used as a tool for early clinical diagnosis of nail melanoma. It involves examining the nail using a special microscope called a dermascope.
If nail melanoma is confirmed, further testing will be ordered to determine the extent of the malignancy and whether it has metastasized to other areas of the body. Staging of the melanoma will be based on the number of cancerous cells present and how the melanoma has spread. Treatment options may include surgery, radiation, and chemotherapy.
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Treatment of nail melanoma
Subungual melanoma, also known as nail unit melanoma, is a type of skin cancer that develops under the nails. It occurs in the nail matrix, which is located at the base of the nail and is responsible for producing keratin. This type of melanoma is often challenging to identify because the discoloration can resemble bruising of the nails.
The most common symptom of subungual melanoma is a discolored line that appears on the nail. It is usually brown or black and runs from top to bottom. In some cases, the line can be irregularly shaped and increase in length and width over time. It can take several months for nail melanoma to grow, and it is often mistaken for other conditions or injuries.
If a physician suspects that a patient might have subungual melanoma, they will likely order a biopsy. They will collect a tissue sample from the affected nail and send it to a pathologist, who will carefully examine the cells to determine if they are cancerous. A dermoscopy may also be performed, where a special microscope called a dermascope is used to examine the nail.
Treatment for subungual melanoma typically involves surgically removing the affected portion of the nail and/or digit. Surgery may be accompanied by radiation therapy, chemotherapy, and/or immunotherapy to prevent or treat the spread of the cancer to other areas of the body. The treatment plan may vary depending on the stage of cancer and the patient's overall health.
It is important to note that subungual melanoma is not correlated with sun exposure. However, it is more common in people of African-American, Asian, or Hispanic descent, and the risk increases with age, typically between 50 and 70 years.
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Risk factors for nail melanoma
While the exact cause of nail melanoma is unknown, healthcare providers believe that certain factors can increase an individual's risk of developing the condition. Unlike cutaneous melanoma, nail melanoma does not appear to be related to sun exposure. Instead, it originates from the activation and proliferation of melanin-producing melanocytes in the nail matrix.
Age: Older adults, particularly those between the ages of 50 and 70, are at a higher risk of developing nail melanoma.
Skin Colour: Individuals with darker skin, especially those of African-American, Asian, Hispanic, Japanese, Chinese, Native American, or African descent, have an increased risk of nail melanoma. It is more prevalent in deeply pigmented individuals and occurs equally in all racial groups.
Family History: A family or personal history of melanoma or dysplastic nevi (atypical moles) can increase the risk of nail melanoma.
Injury or Trauma: Injury or trauma to the nail area may be a contributing factor to nail melanoma. This could include digital trauma or external exposures.
Genetics: Genetic factors can play a role in the development of nail melanoma, although the exact genetic links are still being studied.
Nail Changes: Any changes to the nail, such as discolouration, changes in shape or thickness, lifting or separation from the nail bed, dents or divots, and nail damage like splitting or cracking, can be indicative of nail melanoma. However, these changes may also be caused by other conditions, so a proper diagnosis is important.
It is important to note that nail melanoma is a rare condition, and anyone can develop it. If you notice any suspicious changes to your nails or have any concerns, it is always best to consult with a healthcare professional for a proper diagnosis.
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Melanoma growth and progression
Melanoma is a type of skin cancer that starts in the epidermis, the top layer of skin. When melanoma occurs in or around the nail, it is called subungual melanoma or nail melanoma. It is an uncommon form of melanoma, accounting for about 2-3% of skin melanomas. However, it is the most common type of melanoma diagnosed in deeply pigmented individuals.
Nail melanoma usually starts in the nail matrix, located at the base of the nail, and is responsible for forming new nail growth. It is often a variant of acral lentiginous melanoma, a malignant melanoma originating on the palms and soles of the feet. Unlike other skin cancers, nail melanoma does not appear to be related to sun exposure. Instead, it is associated with the activation and proliferation of melanin-producing melanocytes in the nail matrix. Melanocytes are the cells that give our skin its pigmentation or colour. When these cells are activated, melanin production increases, resulting in hyperpigmentation, which manifests as vertical stripes under the nail.
The most common symptom of nail melanoma is a discoloured line or streak on the nail, typically brown or black, running from top to bottom. This symptom is known as longitudinal melanonychia. Initially, the line may be narrow, but over time, it can become wider, thicker, and more irregular in pigmentation. As the condition progresses, the nail may start to split, crack, thicken, or separate from the nail bed, a condition called onycholysis. Bleeding may also occur around or underneath the nail plate, causing thin red streaks. In some cases, the nail may even fall off completely.
The progression of nail melanoma can lead to nail dystrophy and ulceration, causing cosmetic deformity. Additionally, the cancerous cells can spread to other parts of the body, a process called metastatic spread. To diagnose nail melanoma, a biopsy of the nail matrix and nail bed is typically performed, along with a thorough examination of the patient's history, including medical history, drug use, digital trauma, and any external exposures. While nail melanoma is uncommon, it is important to be vigilant and seek medical advice if any suspicious changes are noticed in the nails.
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Frequently asked questions
Subungual melanoma is skin cancer that forms under the nail. It is a subtype of cutaneous malignant melanoma. It is also known as nail melanoma.
The most common symptom of subungual melanoma is a discoloured line that appears on the nail. It is usually brown or black and runs from top to bottom. The line can be irregularly shaped and increase in length and width over time. Other symptoms include the nail splitting, cracking, thickening or separating from the nail bed.
Treatment for subungual melanoma often involves surgery. During the early stages of the disease, Mohs surgery works well. This procedure removes cancerous cells layer by layer without damaging the surrounding skin. If the cancer has spread, immunotherapy or radiation may be recommended.
