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Subungual haemorrhage

Author: Dr Mirain Phillips, Resident Medical Officer, Waikato Hospital, Hamilton, New Zealand. DermNet NZ Editor in Chief: Adjunct A/Prof. Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. March 2020.


What is subungual haemorrhage?

Subungual haemorrhage describes an area of the nail where blood is located between the nail matrix and nail plate. Subungual haemorrhage (escape of blood) is also called subungual hematoma (collection of blood).

Subungual haemorrhage

See more images of subungual haemorrhage.

What causes subungual haemorrhage?

Subungual haemorrhage is caused by an injury to the nail [1–3].

The types of precipitating injury may include:

  • A recalled painful event (eg, crush injury or blunt trauma)
  • A non-recalled repetitive micro-trauma (eg, tight or ill-fitting shoes).

Rarely, subungual haemorrhage is associated with a malignant tumour of the nail unit, such as squamous cell carcinoma or melanoma.

What are the clinical features of subungual haemorrhage?

Subungual haemorrhage presents as a discoloured or pigmented nail, which may be painless, tender, or painful.

The patient may remember an injury leading to intense pain due to the pressure from the pooling of blood in an enclosed space and damage to surrounding tissues. Reactive inflammatory changes, such as swelling and erythema, may be observed around the nail fold shortly after the injury.

The trauma may destroy or fracture the nail plate, which may be opaque and yellowish as it is detached from the nail bed (onycholysis). The hyponychium (the skin under the free distal edge of the nail) may appear thickened due to blood between the nail plate and the nail bed.

Subungual haemorrhage may appear reddish, purple, brown, black, or a combination of these colours. The variation in colour is related to the duration and stage of healing [2].

A clear proximal margin in the nail plate appears within a few weeks due to normal nail growth after the injury and the discoloured nail plate grows outwards.

Subungual haemorrhage

How is subungual haemorrhage diagnosed?

Subungual haemorrhage is a clinical diagnosis supported by dermoscopy.

The dermoscopic features of subungual haemorrhage include [2–4]:

  • Homogeneous or variable colours (reddish, purple, brown, or black)
  • Peripheral globular structures (also called clods) and streaks
  • Peripheral fading
  • Periungual haemorrhage
  • Linear white marks on the nail plate due to loss of transparency
  • Distal yellowing of the nail plate
  • Lack of malignant features.

The assessment of a pigmented nail should always evaluate the features that might be suggestive of subungual melanoma [4].

Subungual haemorrhage dermoscopy

What is the differential diagnosis for subungual haemorrhage?

The differential diagnoses to consider for nail pigmentation include:

Nail unit melanoma appears as a pigmented linear or triangular band along the entire length of the nail plate. It develops the following features over time:

  • Irregularity in pigmentation (light brown, dark brown, grey, or black)
  • Irregularity in the width and spacing of the pigmented bands
  • Ulceration or bleeding
  • Hutchinson sign (pigmentation in the skin proximal to the nail plate) and micro-Hutchinson sign (skin pigmentation visible on dermoscopy but not on clinical examination)
  • Nail dystrophy (cracking or deformity of the nail)
  • Subungual haemorrhage.

A normal-appearing proximal nail excludes a melanocytic lesion [5].

What is the treatment for subungual haemorrhage?

No treatment is required for subungual haemorrhage in the majority of cases. In the case of repetitive subungual haemorrhage, precipitating factors should be avoided, such as tight or ill-fitting shoes.

In the case of diagnostic uncertainty, the nail should be monitored.

If subungual haemorrhage is acutely painful (< 48 hours after the injury), trephination can be considered [6,7]. Small holes are made in the nail plate to decompress and drain the haematoma.

Occasionally the nail plate is best removed, and the nailbed surgically repaired. A surgical opinion should be sought if there is an underlying fracture [7].

Subungual haemorrhage surgery

What is the outcome for subungual haemorrhage?

Subungual haemorrhage is slow to resolve. It can take several months to years for the nail to appear normal, with toenails taking longer than fingernails to recover.

Progression of subungual haemorrhage

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References

  1. Nevares-Pomales O, Sarriera-Lazaro C, Barrera-Llaurador J, Santiago-Vazquez M, Lugo-Fagundo N, Sanchez J, et al. Pigmented Lesions of the Nail Unit. Am J Dermatopathol 2018; 40: 793–804. PubMed
  2. Alessandrini A, Starace M, Piraccini B. Dermoscopy in the Evaluation of Nail Disorders. Skin Appendage Disord 2017; 3: 70–82. PubMed Central
  3. Mun J, Kim G, Jwa S, Song M, Kim H, Ko H, et al. Dermoscopy of subungual haemorrhage: its usefulness in differential diagnosis from nail-unit melanoma. Br J Dermatol 2013; 168: 1224–9. PubMed
  4. Phan A, Dalle S, Touzet S, Ronger-Savlé S, Balme B, Thomas L. Dermoscopic features of acral lentiginous melanoma in a large series of 110 cases in a white population. Br J Dermatol 2009; 162: 765–71. PubMed
  5. Fountain J. Recognition of subungual hematoma as an imitator of subungual melanoma. J Am Acad Dermatol 1990; 23: 773. PubMed
  6. Farrington G. Subungual Haematoma--An Evaluation of Treatment. BMJ 1964; 1: 742–4. PubMed Central
  7. Pingel C, McDowell C. Subungual Hematoma Drainage. NCBI 2019. Available from: www.ncbi.nlm.nih.gov/books/NBK482508 [cited 3 February 2020]

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