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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_141_библиотеки_им_акад_М_И_Перельмана
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Fig. 98.3 Facial lesions of acquired ichthyosis
98 Acquired Ichthyosis
observed in adults after puberty without a family history,
an investigation for possible causes of acquired ichthyosis
is needed. Histopathologically, it is known to show hyperkeratosis of the epidermis and decrease or loss of the
granular layer, similar to ichthyosis vulgaris. If the underlying disease is treated or the triggering drug is discontinued, the skin lesions tend to improve. Because the skin
barrier function is decreased and there is a lot of water
loss through the skin, symptomatic treatment is used to
supply moisture to the skin and promote lubrication and
keratolysis. For H, I prescribed a cream and moisturizer
that are effective for itching, hyperkeratosis, and dryness
and told his father that a comprehensive examination is
needed to nd the cause of the student’s acquired ichthyosis (Figs. 98.3, 98.4, 98.5, 98.6, 98.7, 98.8, 98.9 and
98.10).
Figs. 98.4 and 98.5 Acquired ichthyosis of the arm
Figs. 98.6 and 98.7 Acquired ichthyosis of the trunk
98 Acquired Ichthyosis
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Figs. 98.8 and 98.9 Acquired ichthyosis observed on the leg
405
Fig. 98.10 Acquired ichthyosis
Black Heel, Talon Noir, Calcaneal
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Petechiae
99
I recently noticed black spots on my heel, could this be a
serious disease? (Fig.99.1).
Mr. Y, who was almost a professional tennis player during
his school days, recently rediscovered his love for tennis
with his wife. One day, while taking a bath, he was startled
to nd many black spots on his heel. That’s because he
recently heard that dark spots on the skin could be skin
cancer.
When playing sports like basketball, volleyball, and tennis,
sudden stops, starts, and jumps can cause a large number of
irregular black spots to appear on the heel. This is known as
black heel (talon noir/traumatic calcaneal petechiae), and it
is thought to be caused by the rupture of small blood vessels
in the dermal papillae due to friction and twisting between
the heel and shoes during vigorous exercise. It was rst
Fig. 99.1 Black heel (calcaneal petechiae)
described in 1961. It often occurs in adolescents who are
physically active and is characterized by the sudden appearance of black or dark blue spots on the back or side of the
heel. In many cases, the skin around the pigmented spots can
be seen to be hyperkeratotic. It is relatively common, but
because it is asymptomatic, naturally disappears, and occurs
in a location that is difcult to check with the naked eye, it is
usually discovered accidentally by the individual or someone
else. It usually appears on one foot but can sometimes be
observed on both feet, and there have been cases reported
where it has appeared on the front of the foot, toes, and
hands. When similar signs appear on the palm, it is called
black palm. It can occur in mogul skiers who repeatedly hit
the snow with their poles, tennis players who hit the ball
hard, or people who practice golf intensively.
An important point about this condition is that if a large
number of black spots merge, it can be confused with melanoma. When repeatedly cut with a scalpel, a characteristic appearance of reddish-brown dried hemorrhagic
material is observed. Once this disease is experienced, the
diagnosis can be easily made based on the location of the
lesion, age, exercise, sudden occurrence, and characteristics after cutting with a scalpel. However, it can be difcult
to diagnose if the lesion occurs in areas other than the heel.
Histologically, you can observe amorphous material of a
yellowish-brown color gathered in a round shape in the
epidermis and stratum corneum. This is due to the agglomeration of red blood cells from bleeding at the tip of the
dermal papillae. It is not necessary to treat it as it will disappear on its own once the cause is gone, but local heat
fomentation with a thermal pack can help calm the lesion,
and continuous trimming alone can remove the lesion.
After hearing the detailed explanation, Mr. Y left the clinic
with a relieved expression (Figs.99.2, 99.3, 99.4, 99.5,
99.6 and 99.7).
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_99
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Fig. 99.2 Black heel
99 Black Heel, Talon Noir, Calcaneal Petechiae
Fig. 99.3 Black heel
Figs. 99.4 and 99.5 Black spots observed on the big toe area
Figs. 99.6 and 99.7 Black palm occurred after golf practice
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100
One day, I have a black line on my nail. Is it skin cancer?
(Figs.100.1–100.3).
Mr. J, a man in his 50s, was deeply troubled. He had read
an internet article saying that the black line that had appeared
on his nail could be a symptom of skin cancer, melanoma.
Many people come to check if the black spots on their skin
or the black lines on their nails are signs of a serious disease,
but Mr. J seems to be particularly nervous. However, there is
no need to worry in advance.
One of the common concerns encountered in the clinic,
but often lacking a clear answer, is the black line that appears
on the nails. Melanonychia refer to the nails turning black or
Figs. 100.1–100.3 Before and after treatment of melanonychia with Q-switched Nd:YAG laser
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_100
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100 Melanonychia
brown without pain or itching. In a narrow sense, it refers
only to those caused by melanin pigmentation, and in a broad
sense, it includes all cases that can cause black or brown pigmentation on the nails, but since the components of the pigment cannot be conrmed with the naked eye, it is considered
rationale to apply a broad denition in dening black nails
clinically. Nail pigmentation can appear clinically in longitudinal, local, extensive, and transverse forms, but among
them, the case where pigmentation occurs along the longitudinal axis where the nail plate grows is called longitudinal
melanonychia. Longitudinal melanonychia is understood as
a phenomenon where melanin pigment production increases
in most cases from the nail matrix, and as a result, melanin
pigment is deposited on the nail plate.
The difference between the melanocytes of the nail matrix
and the melanocytes of the surrounding skin is that the numbers are small, most are not activated, and they are distributed in the lower 2–4 cell layers of the nail matrix. The
causes of melanonychia can be divided into those of melanocyte origin and those not of melanocyte origin. Melanocyte
origin can be divided into increased melanocyte activity
(melanocytic activation, melanocytic stimulation, functional
melanonychia), benign melanocytic proliferation, atypical
melanocytic proliferation, melanoma in situ, and malignant
melanoma according to histological features. Increased
melanocyte activity means an increase in melanin pigment in
the basal cell layer without an increase in the number of
melanocytes. Benign melanocytic proliferation is accompanied by an increase in the number of melanocytes, and if the
melanocytes do not form a nest, it is called a lentigo, and if
the melanocytes form one or more nests, it is called a mela-
nocytic nevus. If the number of melanocytes increases and
some atypical nuclei and Paget’s disease-like spread appear,
it is called atypical melanocytic proliferation, and differentiation from melanoma in situ is necessary. Unlike melanoma
in situ, atypical melanocytic proliferation does not show
highly atypical nuclei, high transepidermal migration of
melanocytes, or disruption of epidermal contour. Clinically,
there is still controversy over whether atypical melanocytic
proliferation can cause malignant changes in the future, but
surgical removal is necessary for preventive purposes
(Figs. 100.4, 100.5–100.7, 100.8, 100.9, 100.10, 100.11,
100.12 and 100.13).
Malignant melanoma shows differences in incidence and
predilection sites depending on race and environmental fac-
Fig. 100.4 Longitudinal melanonychia
Figs. 100.5–100.7 Longitudinal melanonychia
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Figs. 100.8 and 100.9 Longitudinal melanonychia
411
Figs. 100.10 and 100.11 10× magnication of longitudinal melanonychia
Figs. 100.12 and 100.13 10× magnication of longitudinal melanonychia
tors, and the prevalence of longitudinal melanonychia also
differs by race, with 1% in whites, 77% in blacks, and
10–20% in Asians. About 6% of adults with longitudinal
melanonychia have been conrmed to have malignant melanoma, but it is extremely rare for longitudinal melanonychia
in children to be diagnosed as subungual melanoma. In a
study of 75 patients with longitudinal melanonychia in
Korea, 11 patients (14.7%) were classied as malignant diseases, consisting of 6 malignant melanomas (8.0%), 3 melanomas in situ (4.0%), and 2 atypical melanocytic
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proliferations (2.7%). Sixty-four patients (85.3%) were classied as benign diseases, consisting of 49 with melanocytic
activation (65.3%), 5 with melanocytic nevi (6.7%), 5 with
hemorrhage (6.7%), 4 with onychomycosis (5.3%), and 1
person with nger mucous cysts (1.3%). Of the 58 patients
who had longitudinal melanonychia on only one nail plate,
11 (19.0%) were classied as malignant diseases, as were 11
of the 40 patients (27.5%) whose pigmented bands were not
uniform in color, 10 of the 12 patients (83.3%) who showed
Hutchinson’s sign, and 9 of the 20 patients (45.0%) who had
deformities or ulcers of the nail plate. All 15 patients (100%)
diagnosed at age 18 or younger, 21 of the 22 patients (95.5%)
who were 18 or younger at onset, all 17 patients (100%) who
had more than one nail plate affected, all 35 patients (100%)
whose pigmented bands were uniform in color, 47 of the 48
patients (97.9%) whose pigmented bands were less than half
the width of the entire nail plate, 62 of the 63 patients (98.4%)
who did not show Hutchinson’s sign, and 53 of the 55
patients (96.4%) who did not have deformities or ulcers of
the nail plate were classied as benign diseases. In other
words, all 11 patients with longitudinal melanonychia classied as malignant diseases had it on only one nail plate, all 11
had pigmented bands that were not uniform in color, 10
(90.9%) showed positive ndings for Hutchinson’s sign, and
9 (81.8%) had deformities or ulcers of the nail plate. Of the
64 patients with longitudinal melanonychia classied as
benign diseases, 62 (96.9%) did not show Hutchinson’s sign,
and 53 (82.8%) did not have deformities or ulcers of the nail
plate. The age group in which subungual malignant melanoma is most commonly diagnosed is known to be in the 40s
and 50s, and the locations where subungual malignant melanoma is most commonly diagnosed are reported to be the
thumb, index nger, and big toe.
Hutchinson’s Nail Sign
This refers to the spread of brown or black pigment
from the nail bed, matrix, and nail plate to the adjacent
cuticle and the proximal or lateral nail fold. It is an
important clinical clue for subungual melanoma. It
was rst described by Hutchinson in 1886. Hutchinson’s
sign is also observed in malignant tumors of the nail
unit other than melanoma, such as squamous cell carcinoma in situ (Bowen’s disease) and basal cell carcinoma, benign tumors such as onychomatricoma and
supercial acral bromyxoma, and nail and mucosa
pigmentation disorders such as Peutz–Jeghers syndrome or Laugier–Hunziker syndrome. Also, it is
observed in nevus of the nail unit, systemic conditions
(AIDS, pregnancy, malnutrition), drug use (minocy-
100 Melanonychia
cline, zidovudine, amlodipine, hydroxycarbamide),
fungal and bacterial infections, trauma-induced pigmentation, post-inammatory hyperpigmentation,
radiation therapy, and silver nitrate staining. The
excessive pigmentation of the nail bed or matrix, which
is similar to Hutchinson’s sign and can be seen through
the transparent nail folds, is not uncommon and is
referred to as “pseudo-Hutchinson’s sign.” However,
in these cases, it is only observed directly above the
pigmented band. There is also a “micro-Hutchinson’s
sign,” which is pigmentation of the epidermis that is
not visible to the naked eye but can be conrmed with
a dermoscope (Figs.100.14–100.16).
The three steps in diagnosing melanonychia are (1) distin-
guishing whether the pigmentation of the nail is melanin or
not, (2) determining whether the occurrence of melanonychia
is due to the activation or proliferation of matrix melanocytes, and (3) if it is due to proliferation, evaluating whether
it is benign or malignant. Melanonychia can be caused by a
variety of diseases, including subungual hematoma, onychomycosis, drug side effects, melanocytic nevus, lentigo simplex, melanocytic hyperplasia, and subungual melanoma.
Among these, the most attention is required for differential
diagnosis of subungual melanoma. Usually, subungual
hematoma and onychomycosis do not show longitudinal pigmentation clinically and are relatively easy to diagnose due
to the history of trauma and changes in nail shape. Transverse
melanonychia is rare, but it has been reported in patients who
have used drugs such as anticancer drugs (cyclophosphamide, hydroxyurea, adriamycin), antimalarial drugs (amodiaquine, quinacrine, chloroquine), antiviral drugs (zidovudine,
lamivudine), iniximab, and imatinib. Other pigmented diseases, including melanocytic nevus, always need to be differentiated from malignant melanoma, so it is not easy to
determine the diagnosis and treatment plan. In the case of
longitudinal melanonychia, the most certain way to determine whether the cause of the increase in melanin pigment in
the nail bed is a benign or malignant disease is to perform a
biopsy on the nail bed. However, because nail biopsy is invasive, it is problematic because it often causes cosmetic problems, including permanent deformation of the nail. Especially
in children, it is not easy to decide to perform a biopsy solely
for diagnosis, as it can lead to deformation of the nails for the
rest of their lives. Therefore, if we are aware of the possibility that malignant disease is the cause and the clinical ndings suggesting malignancy and benignity, and if we can
perform a biopsy selectively considering the patient’s daily
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413
Figs. 100.14–100.16 Cases that received a biopsy due to being mistaken for Hutchinson’s sign
exogenous melanonychia have other substances attached to
the nail plate and usually do not show a striped pattern. The
most common non-melanin pigmentation is subungual
hematoma, onychomycosis, and Pseudomonas infection.
The number of affected ngers is also important, and if more
than one is affected, it should rst be considered due to the
activation of melanocytes, such as drug-induced melanonychia, and a gray background of the band and thin gray parallel lines are observed. If only one nger is affected, the
proliferation process of melanocytes should be considered,
and in such cases, it becomes a dilemma to distinguish
between malignant and benign. The color of the band can be
cloudy or clear, the boundaries can be clear or faint, and the
width can range from very thin to covering the entire nail.
Fig. 100.17 Acral lentiginous melanoma
The nail plate can change or be completely normal. And
black-brown pigmentation around the nails (Hutchinson’s
sign) can also be observed. The rst thing to consider in lonlife, it will be helpful in improving the patient’s quality of
life (Fig.100.17).
Dermoscopy can be usefully used in the rst step of diagnosing melanonychia. Generally, melanin pigmentation
appears as black-brown stripes within the nail plate. However,
gitudinal melanonychia due to melanocytic proliferation is
the patient’s age, as the nail matrix nevus appears mainly in
childhood, congenitally or acquired, and ungual melanoma
in children is extremely rare, so clinical and dermoscopic
ndings applied to adults are useless in children.
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100 Melanonychia
Since 2007, dermoscopy has been attempted for the evaluation of pigmentation of adult nails, but the results are not
always reliable, so it should be evaluated together with the
clinical “ABCDEF rule” as much as possible. Dermoscopic
ndings indicate that the risk of nding ungual melanoma is
three times higher if (1) the width of the band is more than
2/3 of the entire nail plate, (2) the presence of gray-black
tones, and (3) there is onychodystrophy. Dermoscopy of the
hyponychium and the tissue around the nails has been
reported to potentially contribute to the diagnosis of melanoma by early detection of “micro-Hutchinson’s sign.”
Dermoscopy is also used to observe the pigment pattern of
the nail matrix, where (1) a regular gray pattern indicates
hypermelanosis, (2) a regular brown pattern indicates benign
melanocytic proliferation, (3) a regular brown pattern with
globules or spots indicates melanocytic nevus, and (4) an
irregular pattern is classied as melanoma. Such dermoscopy
performed during surgery has been reported to help select
the most suitable site for biopsy. Differential diagnosis of
nail diseases can sometimes be very difcult and uncertain,
especially in the evaluation of nail pigmentation. Although
the use of magnifying glasses such as dermoscopy is gradually increasing, there are reports that magnifying glasses
examination should not be used as a substitute for histopathological examination, and it is recommended to perform
excisional biopsy in all cases of longitudinal melanonychia
suspected of melanoma. When a patient with longitudinal
melanonychia visits, it is impossible to conrm whether the
disease is benign or malignant based on clinical ndings
alone, so Mannava etal. suggested the following indications
for suspecting malignant disease and performing a biopsy.
However, I would like to add item No.12 here (Table100.1).
Especially, children, the frequency of malignant melanoma of the nails is very low, so it is generally believed that
tissue biopsy should be reserved until the age of 10, even if
the pigmented area of the nail plate widens or darkens
through regular observation. Also, when malignant melanoma is suspected, a biopsy including the nail matrix and
Table 100.1 Indications for biopsy in longitudinal melanonychia
No. Indications for biopsy in longitudinal melanonychia
1 Any new LM in a fair-skinned patient
2 LM of one nail only
3 Any history of change in LM lesion
4 Width>6mm
5 Proximal width>distal width
6 Heterogeneous pigment (multi-colored)
7 Blurry or jagged borders
8 Associated nail fold pigment (Hutchinson’s sign)
9 Associated nail plate dystrophy, bleeding, or ulceration
10 High-risk digit involved (thumb, index nger, great toe)
11 Personal or family history of melanoma
12 No response to Q-switched Nd:YAG laser
Table 100.2
diseases in longitudinal melanonychia
Comparison
Age of onset Under 18 Over 40s and 50s
Number of
involved nails
Color of
pigment band
Border of
pigment band
Width of
pigment band
Hutchinson’s
sign
Changes in the
nail plate
Nail location Other ngers and toes Thumb, index nger,
Response to
Q-switched
laser
Comparison of the likelihood of benign and malignant
Findings with a high
likelihood of benign
disease
More than two One
Homogeneous Heterogeneous
Clear Blurry
Less than 6mm Greater than 6mm
Doesn’t appear Appear
Unaccompanied Accompanied by
Yes No
Findings with a high
likelihood of malignant
disease
dystrophy, bleeding, or
ulceration
or big toe
nail bed is effective for accurate diagnosis, but it can permanently cause nail deformity, so it is also considered to perform a punch biopsy at 2–3 sites using a 2–3mm punch after
removing part of the nail plate, but it is only attempted in
very exceptional cases under the age of 14 (Table100.2).
In adults, dermoscopy or biopsy is necessary for accurate
differential diagnosis of melanonychia, and surgical operation is the rst choice for the treatment of subungual melanoma. However, there is still no consensus on the treatment
policy for longitudinal melanonychia in children. In a Korean
study that analyzed 158 black nails from 92 patients with
melanonychia striata under the age of 5 and followed up for
an average of 27.8months in 80 patients who returned for a
return visit, all of them, including eight cases in which biopsies were performed, were clinically benign. Progress was
shown, and 39% of cases maintained the initial condition during the follow-up period, and 44% of cases showed spontaneous improvement by shrinking or softening. In some cases,
changes such as darkening or widening of the pigment band
were observed, and although a biopsy was performed in a few
cases, no ndings suspicious of malignancy were conrmed.
Therefore, it has been suggested that not only invasive biopsy
but also regular follow-up observation can be a good treatment policy. There have been reports on the effect of 755nm
Q-switched Alexandrite for the treatment of melanonychia
accompanied by onychomycosis. In the case of longitudinal
melanonychia caused by increased melanocyte activity rather
than proliferation of melanocytes, treatment using Q-switched
Nd:YAG laser has been effective. There are cases where the
pigment band disappears without recurrence after 5–10 treatments at one-week intervals. Since 2010, the treatment of
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