Subungual Melanoma

Aka: Subungual Melanoma, Ungual Melanoma, Hutchinson Nail Sign, Hutchinson's Nail Sign, Hutchinson's Melanotic Whitlow, Acral Lentiginous Melanoma

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II. Epidemiology

  1. Represents 2.5% of Melanomas
  2. Account for 50% of Melanomas in dark skinned patients

III. Pathophysiology

  1. Type of Acral Lentiginous Melanoma

IV. Characteristics

  1. Longitudinal brown-black streak
  2. May encompass entire nail
  3. Hutchinson's Nail Sign
    1. Melanoma affecting proximal nail fold skin

V. Evaluation: Factors suggesting Melanoma

  1. Recent change (e.g. band wider or darker)
  2. Hutchinson's Nail Sign (see above)
  3. Individual nail involvement (especially first digit)
  4. Longitudinal band >3 mm wide (or widens at the proximal nail)
  5. Nail plate disruption
  6. New onset in caucasian or age >60 years
    1. May be normal variant in dark-skinned patients
    2. However, Melanoma also occurs in dark-skin patients

VI. Differential Diagnosis

  1. See Melanonychia
  2. Nail Longitudinal Band

VII. Management

  1. Acral Lentiginous Melanoma is a very aggressive tumor with early metastasis even from small lesions

VIII. Prognosis

  1. Five year survival is as low as 50%

IX. References

  1. Habif (2003) Clinical Dermatology, 4th ed.. Mosby, p. 773-813
  2. Rager (2005) Am Fam Physician 72:269-76 [PubMed]

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