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Hi there,

I saw a new patient yesterday who has noticed occasional bleeding from under her big toenail when she wears closed in shoes. It is not painful and the only reason she is aware of it is she notices the blood stain on her sock / stocking or someone else points it out to her. This has been going on for one month.

She is a 67 year old lady of Italian descent who is on medication for myocarditis and cholesterol and also taking asprin.

Upon examination, there was a mildly dark discolouration under the nail. It was elongated (narrow and long and running from proximal to distal) but only 1/3 of the length of the nail. The discolouration was mid-nail: it did not extend from the proximal end or extend to the distal end of the nail. So I’m assuming this isn’t a melanoma.

It looked very much like a minor bruise under the nail and it was only tender at most to direct palpation (ie: no tenderness palpating distal, proximal or adjacent nail plate.

My plan was to clear the nail from the sulcus and thin the nail as much as possible over the adjacent area so as to remove as much pressure as possible. Until this point I was suspecting that whatever the problem was we were at the back end of it and it had all but resolved. But cutting the nail back to the area caused it to bleed much more that I was expecting and more than what a ‘nick’ would produce, even though she is on asprin. As I revealed the nail bed, the tissue became quite spongy and because it was bleeding a lot, it was difficult to see what was what but the tissue didn't seem like normal nailbed tissue. It did get painful the more I poked around at it, which was quite understandable!

I intend to see her in 2 weeks to see if anything has changed with the removing of pressure … and to investigate a differential diagnosis other than melanoma and subungual exostosis. I’ve read about glomus tumours, but these are usually painful (this one isn’t) especially under cold water (she didn’t mention this but I didn’t ask).

Any advice on this vascular and minimally painful subungual lesion would be gratefully received!

Rebecca

 

Sounds like a sub-ungual pressure lesion, but a photo would be useful to help identify.

 

Cheers David!

 

Pyogenic Granuloma?

 

This sounds a lot like what I saw. Thanks for that Paul!

 

They occur commonly under nails, plantar foot and in between toes. Easy solved, cut the nail back as far as possible (may require anaesthesia to do this) - remove the lesion - send it for histology to check and then cauterize the lesion (we normally use phenol for sub ungual lesions like this). Review after a few days and it should all be healed. They tend to bleed prolifically due to their nature so control of that is a necessity, usually a tournicot will suffice. Key is: always histopath!

 

Hello Asher

I had something very similar earlier this year. Similar history to your patient. I sent my patient to her GP twice and wrote to her GP twice who did nothing and the GP told the patient there was nothing to worry about. I then referred her to a consultant dermatologist who said it was a fungal infection even though she took clippings and they were negative along with the obvious clinical features that it was NOT a fungal infection. Toenail doesn't look, behave or in any way appear as a fungal infection. I was totally frustrated especially when this consultant dermatologist wrote back to her GP saying she should taking 3/12's of lamisil (84 year old woman on those toxic drugs!)

I see this lady every 6 weeks and during the last appointment it went as you described with your patient as above with regards some discharge and the nail looking slightly detached and just trimming the nail back to release the exudate........I rang a colleague immediately who is a podiatric surgeon at a local hospital and he saw her within 48hrs and she is now booked for a biopsy. Appalling that the NHS and a private consultant dermatologist paid it no interest. She has already been told they are wanting to rule out malignancy before they do anything else.

My mantra "if it's odd, it's odd"

I'll let you know what her results are.

Jen