Arch Hand Microsurg.  2023 Sep;28(3):125-136. 10.12790/ahm.22.0072.

Diagnosis and treatment of subungual melanoma

• Oh JS
• Kim BJ

• KMID: 2545523
• DOI: http://doi.org/10.12790/ahm.22.0072

Abstract

Subungual melanoma (SM) must be suspected in the initial workup of patients with pigmented nails. However, the differential diagnosis of SM from other nail disorders that involve nail pigmentation is challenging. Dermoscopic, clinical, and histopathological features are integrated for a definite diagnosis. The primary treatment of SM is surgery. Depending on the depth of invasion, amputation or functional surgery can be chosen. This article reviews the clinical, dermoscopic, and histopathological features of SM, as well as its diagnosis and treatment.

Keyword

Nail diseases; Melanoma; Melanocytes

Figure

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  Fig. 1. Nail malignant melanoma in a 74-year-old female patient. (A) Patient presenting longitudinal melanonychia (black arrow) and Hutchinson sign (red arrow) involving the left second digit. (B) Dermoscopy showing irregular, multicolor pattern.Written informed consent was obtained for publication of these images.

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  Fig. 2. Histopathology of melanoma in situ of a 51-year-old female patient showing atypical melanocytes. (A) H&E stain, ×400. (B) HMB45 stain, ×400.

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  Fig. 3. (A) A 56-year-old female patient presented with left thumb subungual melanoma with a thickness of 6 mm. (B) Elevation of serratus anterior fascial free flap from the left side through a lazy S-shaped incision near the anterior border of latissimus dorsi muscle. Micro-anastomosis of serratus collateral artery to the ulnar digital proper artery was done. Flap was placed with the deeper side turning up and covered with split-thickness skin graft. (C) Appearance of the foot 2 years postoperatively with no recurrence. The length, width, and thickness of the thumb tip were preserved. Two-point discrimination was 6.5 mm at the middle of flap in the left distal phalanx. (D) Clinical photograph of reconstructed nail apparatus and acral skin in interphalangeal joint (IPJ) flexion. Range of motion at the IPJ was 85° which was similar to the contralateral side thumb. The patient was very satisfied with the functional and esthetic results. Written informed consent was obtained for publication of these images.

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  Fig. 4. A 36-year-old female patient with subungual melanoma on the left third finger. (A) Preoperative clinical photograph. (B) En bloc excision of the tumor and nail complex with a 5-mm margin. (C) A venous flap harvested from the volar side of the left forearm was anastomosed with one digital artery and two digital veins. (D) Natural contour of the reconstructed finger without any complications at the 8-month follow-up. Reprinted from Woo et al. [70], according to the Creative Commons License.

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  Fig. 5. A 64-year-old female patient with subungual melanoma on the right first toe. (A) Preoperative clinical photograph. (B) After inset of a venous flap harvested from the dorsal side of the right foot to allow reversed blood flow with the against-valve type. (C) Clinical photograph of a skin defect that occurred at the center of the flap due to trauma 3 months after surgery. (D) Completely healed flap without further treatment at a 5-year follow-up after debridement and skin grafting for the skin defect. Reprinted from Woo et al. [70], according to the Creative Commons License.

Reference

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