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By Alan J. Himmelsbach, NP, and Stephen M. Schleicher, MD
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CASE:
An elderly woman is brought in from her nursing home for evaluation of a dystrophic nail. She denies antecedent trauma to the area but her mentation is poor and she seems somewhat confused. The consultation sheet from her care facility reveals she is on multiple medications but also gives no history of trauma. On physical examination, the patient appears well nourished with no significant joint changes of the fingers. The affected nail manifests proximal dystrophy and a well-demarcated, linear, hyperpigmented band. There is no diffusion of pigment. A biopsy is obtained.
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Nail pigmentation can pose a diagnostic challenge, with common etiologies ranging from trauma to bacterial infection with Pseudomonas (the latter imparting a blue-green hue). Discoloration under the nail is most frequently due to subungual hemorrhage and a history of trauma is usually elicited. More seriously, subungual pigmentation may be caused by malignant melanoma. This condition commonly manifests as a hyperpigmented band running the length of the nail plate. Diffusion of pigment into the nail folds is known as the Hutchinson sign. The prognosis in these cases is guarded and the treatment of choice is either complete or partial amputation of the finger. This patient’s biopsy results were compatible with a traumatic incident. |
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Alan J. Himmelsbach is on the staff of DermDx Centers for Dermatology in Reading, Pennsylvania. Dr. Schleicher is director of DermDx Centers and a clinical instructor of dermatology at the Philadelphia College of Osteopathic Medicine, at Kings College in Wilkes-Barre, Pennsylvania, and at Arcadia University in Glenside, Pennsylvania. He is also a member of the EMERGENCY MEDICINE editorial board.
Emerg Med 41(2):23-24, 2009
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