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this was sent from my freind. i know the pic is blurred (mobile pic) he noticed this lesion for 3 weeks not painful no hx of trauma before , it started as such, no previos lesion.
so somone told him that it needs to be biopsied (it could be cancer)! he was worried . since he s living in another city i couldnt see him but i referred him to another Dr there.
i had no doubt that it was trauma induced (history is not necessary it could have happend while he was sleeeping), the nice smooth outline and the erythematous margins negates melanoma.
he called me later and said that it peeled off!
but what can cause confusion in my opinion is the periungual hemmorrage that can mimic a hutchinson sign. they can produce melanonychia. whats even more challanging are hemoorages underneath the nails. they can presnet in many shapes and persist for long and provoke alotta worry and unnessasary biopsies. furthermore trauma was linked to periungual melanoma in a few case reports.
my question is: when do we have to biopsy a subungual lesion (dark brown) underneath the nail?
Filed under: Uncategorized | Tagged: melanoma
dermlive
dermis111
dr660
skindr
visitor111
epiderma
kamalsaleh
very interesting topic could have discussion on it for ages and not reach a conclusion,,,, many of these patients present to us in clinic and we are faced with this same question to biopsy or not specially in kids and from here i think to gain an experience with dermoscopy may add to some extent i heard about a dermatologist in New york who has a special interest in dermoscopy of nails and can tell with a great confidence if the lesion is a melanoma or not. bottom line we use our judgment and experience to decide whether to biopsy or to follow. interesting topic would like to know what does the others think
The presence of this lesion for 3 weeks only even in the abscence of story of trauma makes me reluctant to do the biopsy, I will observe him for 2 weeks and if no change I will go for shave biopsy and not excisional or punch because I want to determine the nature of the lesion first, pihmented or not pigmented, and because suturing on the sole will leave permanent painful fibrotic scar at site of pressue.
dermoscopy is never reliable(at least so far) to tell if this lesion is pigmented or not, dermoscopy does not give enough confidence for the patient because there are no official report issued (depends on the dermatologist skill), a big failure of dermoscopy that it can not detect nonpigmented(amelanotic melanoma) and at the same time fails to clearly diagnose pigmented basal cell carcinoma, ongoing studies are now done to compare between the reliability of dermoscopy and histopathology , Austians are very interested in this .
skin biopsy threshold should be much lower in any suspicious lesions, and keeping guessing is not appropriate.
I will show a case of Acral melanoma in the coming few days.
Best Wishes
To say dermoscopy in never reliable as stated above is preposterous. Dermatoscopes are advanced medical instruments which allow clinicians with the proper traing to EASILY distinguish melanocytic lesions as well as others. Imagine having a specialized eye which hones your clinical powers and allows more accurate diagnoses and aids in bx decisions. Dermoscopes (or dermatoscopes) come in polarized and nopolarized forms allowing identification of epidermal structures, pigments, & adnexal structures. There are numerous atlases and journal articles devoted to the art/science of the field. I am a novice, but know that amelanotic melanoma can be suspected based on atypical vascular patterns whereas pigmented basal cells have many specific structures such as blue grey ovoid nests/maple leaves, etc. A traumatic acral hemorrhage would be easily seen. Get a dermatoscope, some training (Ashfaq Marghoob of MSKCC is an expert who runs an annual conference in NYC), and get some skillz. Dermoscopy will make you a better dermatologist.
As for this acral lesion dermoscopy could easily guide your clincial decision making:
1)if the lesion is pigmented or simply blood
2)if its blood–>trauma, no worries
3)no blood, pigment–> is the pigment in the furrows or rigdes (furrows are fine, rigdes worrisome)
4)is the pigment, symmetric, uniform
simplified; but this type of dermoscopic algorithm would help your dx
hi
the lesion resolved actualy in 3 weeks. so it was just trauma. it doesnt hurt to be obsessive with these lesions though!
thannks