PATIENT PRESENTATION
A 50-year-old man presented with painful purple toes. Earlier that day, all of his toes were asymptomatic and normal in color. He said he noticed that the right great toe and left second toe were tender and discolored after he completed the Chevron Houston Marathon in 3 hours and 54 minutes.
What’s your diagnosis?
Diagnosis: Subungual Hematomas
Subungual hematomas, also referred to as subungual hemorrhages, are usually associated with a traumatic injury to the nail unit. The affected toe or toes in athletes with subungual hematomas can vary depending on the sport (Table 1). In runners, subungual hematomas of the toe nail in athletes results from repeated pounding of the distal foot and toes not only on the running surface but also into the toe box of the shoe or sneaker.1-12 Jogger’s toe or jogger’s toe nail is the term used to describe the following constellation of findings in the third, fourth and fifth toes of runners: erythema, onycholysis, subungual hemorrhage with subsequent nail discoloration. In addition, edema, subungual hyperkeratosis and proximal transverse ridging in the lateral aspects of the toes may be present. Similar to what is seen in this patient, subungual hematomas have also been observed to involve the nails of the great toe and second toe (Figure 1).1,7-11
Clinical Presentation
Sports-related subungual hematomas — that is, of the acute variety — are usually noticed immediately (Table 2). The nail plate and often the surrounding nail folds of the affected toe are red and tender, and blood collects in a space created between the nail plate and the underlying nail bed as the hematoma forms. Intense pain results as the pressure beneath the nail plate increases.13-15 Its presentation in both appearance and symptoms may contrast greatly from those of a chronic subungual hematoma, in which case there is frequently an absence of the symptoms — in fact, the patient may not remember a prior episode of trauma to the often pain-free digit — and the nail plate varies in color from dark blue to purple to black, a clinical scenario that may raise the possibility of subungual melanoma and warrant additional evaluation.13-15
Differential Diagnosis
The differential diagnosis of subungual hematoma in athletes includes onychomycosis and subungual malignant melanoma.
Onychomycosis
Onychomycosis often also presents with concurrent subungual hyperkeratosis. When suspected, a potassium hydroxide examination, fungal culture and/or periodic acid-Schiff staining of the nail plate may be helpful.1,3,7,8
Subungual Melanoma
Recently, in an effort to aid in the differentiation of subungual hemorrhage and subungual melanoma as the cause of black nail pigmentation, a simple and fast method to detect blood pigment in nails was described. After distal free nail edge clipping and subungual scraping, the small fragments of dissolved nail plate are placed on a urinalysis reagent strip and a drop of water is added to soak both the sample and the strips. A green color change is indicative of a positive blood reaction.16 The presence of blood does not necessarily rule out subungual melanoma. Bleeding from the hyponychium or nail bed or both may inadvertently occur after vigorous nail clipping and subungual scraping; hence, the fragments of nail plate would demonstrate a positive blood reaction — even in the presence of a subungual melanoma. Also, a subungual melanoma might have spontaneously bled or the tumor may have been preceded by or only first recognized after trauma to the digit.5,17 The nail plate, without or with (indicating a positive Hutchinson’s sign) inclusion of the proximal nail fold, may be discolored secondary to a subungual melanoma. Epiluminescence microscopy with a dermatoscope may be helpful to differentiate melanoma from hemorrhage. However, a nail matrix and/or nail bed biopsy should be considered if a subungual melanoma is suspected.1,8
Pathology
Following a subungual hematoma, pathologic changes can be observed on light microscope examination of the nail plate and nail bed biopsy specimen. Large collections of homogenous eosinophilic and yellow-brown material are present either within (secondary to transepidermal elimination) and/or beneath the nail plate. The yellow-brown masses represent hemoglobin from the lysed red blood cells.18,19 The amorphous material can be stained brown with the benzidine stain that confirms the presence of hemoglobin; however, since benzidine has been identified as a carcinogen in humans, this stain is not routinely used in histopathology laboratories. The homogenous material stains blue-green with the patent blue V stain. Although this staining method is safe, the stain is not specific for hemoglobin; the nail plate and more keratinizing upper epidermal layers of the nail bed also stain blue-green. Since the amorphous material is hemoglobin, it does not react with stains that demonstrate iron that is deposited in tissue as hemosiderin, such as the prussian blue (Perls’) stain and the Turnbull’s blue stain.18,19
Treatment
The management of acute subungual hematoma focuses on removal of the collection of blood, which results not only in immediate relief of the digital pain but also minimizes any additional injury to the nail bed and nail matrix. Several interventional modalities have been described. These vary with regards to the approach and treatment used to reach the hematoma.
The subungual hematoma can usually be removed within the first 48 hours if it has not organized into a solid mass. The hematoma can be reached proximal to the nail plate by creating an exit route for the blood between the proximal nail fold and the proximal aspect of the nail plate using a toothpick or a flattened wooden applicator or a scalpel.20,21
Alternatively, the hematoma can be evacuated by allowing the blood to escape distally through a space created between the distal nail plate and the hyponychium using either a needle or scalpel blade.20,22
Another intervention, trephination, involves piercing the nail plate overlying the hematoma. Cautiously, slow and gentle pressure is applied to the terphine, which is placed perpendicular to the nail plate until blood exits from the surface of the through and through defect. Either a hot paper clip cautery held with a hemostat, a hot number 18 needle, a scapel blade used as a drill, a hand-held cautery unit or a carbon dioxide laser can be used to terphinate the nail plate. However, in a patient wearing artificial acrylic nails, which are flammable, trephination should not be performed using a hot cautery device.2,8,23-32
Relief of pain is generally immediate following the removal of the hematoma. The nail plate often remains intact following proximal or distal or terphinate decompression treatment of the blood associated with an acute subungual hematoma. However, if the hematoma involves more than 25% of the nail plate, subsequent onycholysis and shedding of the nail plate may occur.8
Avulsion of the nail plate may be necessary to evacuate the hematoma if the lesion is older than 2 days or if there has already been significant injury to the adjacent nail folds, as in this patient. Although systemic antibiotics are often not used following hematoma decompression treatment in which the nail plate remains intact, oral antibiotics to prevent infection are frequently prescribed following complete nail plate removal. One to 1½ years may be necessary for the growth of a new toenail based on an average growth rate of 1 mm per month and a nail length of 1.0 cm to 1.5 cm.2,8,20,33
Prevention
Prevention of subungual hematomas in runners has two components — appropriate footwear and nail hygiene. The running shoes should fit the mid foot snugly, yet comfortably, so that the distal foot is not forced into the toe box — especially when running down hill. Also, the toe box should be adequate so that the most distal nail does not pound into the tip of the shoe. In addition, proper trimming of the nails so that they are straight-cut (and not curved-cut) can help to prevent dystrophy and injury by ensuring equal distribution of forces.3,4,7
Resolution
The reported patient was experiencing severe discomfort and progressive soft tissue injury to the adjacent nail folds of his right great toe (Figure 2); the left second toe tenderness rapidly resolved spontaneously. Complete avulsion of the right great toenail was performed. Double-strength trimethoprim-sulfamethoxazole was prescribed twice daily for 10 days and the wound was cleaned three times each day followed by application of mupirocin 2% ointment. The left second toe was not treated; the distal onycholytic nail plate and associated underlying hematoma were cut back each month. Normal nail plates eventually grew on both toes.
Dr. Cohen is with the University of Houston Health Center, University of Houston, Houston, TX; the Department of Dermatology, The University of Texas; M.D. Anderson Cancer Center, Houston, TX; and the Department of Dermatology, University of Texas-Houston Medical School, Houston, TX.
Dr. Khachemoune, the Section Editor of Derm Dx, is with Department of Dermatology, State University of New York, Brooklyn, NY. Disclosure: The authors have no conflict of interest with any material presented in this column.
PATIENT PRESENTATION
A 50-year-old man presented with painful purple toes. Earlier that day, all of his toes were asymptomatic and normal in color. He said he noticed that the right great toe and left second toe were tender and discolored after he completed the Chevron Houston Marathon in 3 hours and 54 minutes.
What’s your diagnosis?
Diagnosis: Subungual Hematomas
Subungual hematomas, also referred to as subungual hemorrhages, are usually associated with a traumatic injury to the nail unit. The affected toe or toes in athletes with subungual hematomas can vary depending on the sport (Table 1). In runners, subungual hematomas of the toe nail in athletes results from repeated pounding of the distal foot and toes not only on the running surface but also into the toe box of the shoe or sneaker.1-12 Jogger’s toe or jogger’s toe nail is the term used to describe the following constellation of findings in the third, fourth and fifth toes of runners: erythema, onycholysis, subungual hemorrhage with subsequent nail discoloration. In addition, edema, subungual hyperkeratosis and proximal transverse ridging in the lateral aspects of the toes may be present. Similar to what is seen in this patient, subungual hematomas have also been observed to involve the nails of the great toe and second toe (Figure 1).1,7-11
Clinical Presentation
Sports-related subungual hematomas — that is, of the acute variety — are usually noticed immediately (Table 2). The nail plate and often the surrounding nail folds of the affected toe are red and tender, and blood collects in a space created between the nail plate and the underlying nail bed as the hematoma forms. Intense pain results as the pressure beneath the nail plate increases.13-15 Its presentation in both appearance and symptoms may contrast greatly from those of a chronic subungual hematoma, in which case there is frequently an absence of the symptoms — in fact, the patient may not remember a prior episode of trauma to the often pain-free digit — and the nail plate varies in color from dark blue to purple to black, a clinical scenario that may raise the possibility of subungual melanoma and warrant additional evaluation.13-15
Differential Diagnosis
The differential diagnosis of subungual hematoma in athletes includes onychomycosis and subungual malignant melanoma.
Onychomycosis
Onychomycosis often also presents with concurrent subungual hyperkeratosis. When suspected, a potassium hydroxide examination, fungal culture and/or periodic acid-Schiff staining of the nail plate may be helpful.1,3,7,8
Subungual Melanoma
Recently, in an effort to aid in the differentiation of subungual hemorrhage and subungual melanoma as the cause of black nail pigmentation, a simple and fast method to detect blood pigment in nails was described. After distal free nail edge clipping and subungual scraping, the small fragments of dissolved nail plate are placed on a urinalysis reagent strip and a drop of water is added to soak both the sample and the strips. A green color change is indicative of a positive blood reaction.16 The presence of blood does not necessarily rule out subungual melanoma. Bleeding from the hyponychium or nail bed or both may inadvertently occur after vigorous nail clipping and subungual scraping; hence, the fragments of nail plate would demonstrate a positive blood reaction — even in the presence of a subungual melanoma. Also, a subungual melanoma might have spontaneously bled or the tumor may have been preceded by or only first recognized after trauma to the digit.5,17 The nail plate, without or with (indicating a positive Hutchinson’s sign) inclusion of the proximal nail fold, may be discolored secondary to a subungual melanoma. Epiluminescence microscopy with a dermatoscope may be helpful to differentiate melanoma from hemorrhage. However, a nail matrix and/or nail bed biopsy should be considered if a subungual melanoma is suspected.1,8
Pathology
Following a subungual hematoma, pathologic changes can be observed on light microscope examination of the nail plate and nail bed biopsy specimen. Large collections of homogenous eosinophilic and yellow-brown material are present either within (secondary to transepidermal elimination) and/or beneath the nail plate. The yellow-brown masses represent hemoglobin from the lysed red blood cells.18,19 The amorphous material can be stained brown with the benzidine stain that confirms the presence of hemoglobin; however, since benzidine has been identified as a carcinogen in humans, this stain is not routinely used in histopathology laboratories. The homogenous material stains blue-green with the patent blue V stain. Although this staining method is safe, the stain is not specific for hemoglobin; the nail plate and more keratinizing upper epidermal layers of the nail bed also stain blue-green. Since the amorphous material is hemoglobin, it does not react with stains that demonstrate iron that is deposited in tissue as hemosiderin, such as the prussian blue (Perls’) stain and the Turnbull’s blue stain.18,19
Treatment
The management of acute subungual hematoma focuses on removal of the collection of blood, which results not only in immediate relief of the digital pain but also minimizes any additional injury to the nail bed and nail matrix. Several interventional modalities have been described. These vary with regards to the approach and treatment used to reach the hematoma.
The subungual hematoma can usually be removed within the first 48 hours if it has not organized into a solid mass. The hematoma can be reached proximal to the nail plate by creating an exit route for the blood between the proximal nail fold and the proximal aspect of the nail plate using a toothpick or a flattened wooden applicator or a scalpel.20,21
Alternatively, the hematoma can be evacuated by allowing the blood to escape distally through a space created between the distal nail plate and the hyponychium using either a needle or scalpel blade.20,22
Another intervention, trephination, involves piercing the nail plate overlying the hematoma. Cautiously, slow and gentle pressure is applied to the terphine, which is placed perpendicular to the nail plate until blood exits from the surface of the through and through defect. Either a hot paper clip cautery held with a hemostat, a hot number 18 needle, a scapel blade used as a drill, a hand-held cautery unit or a carbon dioxide laser can be used to terphinate the nail plate. However, in a patient wearing artificial acrylic nails, which are flammable, trephination should not be performed using a hot cautery device.2,8,23-32
Relief of pain is generally immediate following the removal of the hematoma. The nail plate often remains intact following proximal or distal or terphinate decompression treatment of the blood associated with an acute subungual hematoma. However, if the hematoma involves more than 25% of the nail plate, subsequent onycholysis and shedding of the nail plate may occur.8
Avulsion of the nail plate may be necessary to evacuate the hematoma if the lesion is older than 2 days or if there has already been significant injury to the adjacent nail folds, as in this patient. Although systemic antibiotics are often not used following hematoma decompression treatment in which the nail plate remains intact, oral antibiotics to prevent infection are frequently prescribed following complete nail plate removal. One to 1½ years may be necessary for the growth of a new toenail based on an average growth rate of 1 mm per month and a nail length of 1.0 cm to 1.5 cm.2,8,20,33
Prevention
Prevention of subungual hematomas in runners has two components — appropriate footwear and nail hygiene. The running shoes should fit the mid foot snugly, yet comfortably, so that the distal foot is not forced into the toe box — especially when running down hill. Also, the toe box should be adequate so that the most distal nail does not pound into the tip of the shoe. In addition, proper trimming of the nails so that they are straight-cut (and not curved-cut) can help to prevent dystrophy and injury by ensuring equal distribution of forces.3,4,7
Resolution
The reported patient was experiencing severe discomfort and progressive soft tissue injury to the adjacent nail folds of his right great toe (Figure 2); the left second toe tenderness rapidly resolved spontaneously. Complete avulsion of the right great toenail was performed. Double-strength trimethoprim-sulfamethoxazole was prescribed twice daily for 10 days and the wound was cleaned three times each day followed by application of mupirocin 2% ointment. The left second toe was not treated; the distal onycholytic nail plate and associated underlying hematoma were cut back each month. Normal nail plates eventually grew on both toes.
Dr. Cohen is with the University of Houston Health Center, University of Houston, Houston, TX; the Department of Dermatology, The University of Texas; M.D. Anderson Cancer Center, Houston, TX; and the Department of Dermatology, University of Texas-Houston Medical School, Houston, TX.
Dr. Khachemoune, the Section Editor of Derm Dx, is with Department of Dermatology, State University of New York, Brooklyn, NY. Disclosure: The authors have no conflict of interest with any material presented in this column.
PATIENT PRESENTATION
A 50-year-old man presented with painful purple toes. Earlier that day, all of his toes were asymptomatic and normal in color. He said he noticed that the right great toe and left second toe were tender and discolored after he completed the Chevron Houston Marathon in 3 hours and 54 minutes.
What’s your diagnosis?
Diagnosis: Subungual Hematomas
Subungual hematomas, also referred to as subungual hemorrhages, are usually associated with a traumatic injury to the nail unit. The affected toe or toes in athletes with subungual hematomas can vary depending on the sport (Table 1). In runners, subungual hematomas of the toe nail in athletes results from repeated pounding of the distal foot and toes not only on the running surface but also into the toe box of the shoe or sneaker.1-12 Jogger’s toe or jogger’s toe nail is the term used to describe the following constellation of findings in the third, fourth and fifth toes of runners: erythema, onycholysis, subungual hemorrhage with subsequent nail discoloration. In addition, edema, subungual hyperkeratosis and proximal transverse ridging in the lateral aspects of the toes may be present. Similar to what is seen in this patient, subungual hematomas have also been observed to involve the nails of the great toe and second toe (Figure 1).1,7-11
Clinical Presentation
Sports-related subungual hematomas — that is, of the acute variety — are usually noticed immediately (Table 2). The nail plate and often the surrounding nail folds of the affected toe are red and tender, and blood collects in a space created between the nail plate and the underlying nail bed as the hematoma forms. Intense pain results as the pressure beneath the nail plate increases.13-15 Its presentation in both appearance and symptoms may contrast greatly from those of a chronic subungual hematoma, in which case there is frequently an absence of the symptoms — in fact, the patient may not remember a prior episode of trauma to the often pain-free digit — and the nail plate varies in color from dark blue to purple to black, a clinical scenario that may raise the possibility of subungual melanoma and warrant additional evaluation.13-15
Differential Diagnosis
The differential diagnosis of subungual hematoma in athletes includes onychomycosis and subungual malignant melanoma.
Onychomycosis
Onychomycosis often also presents with concurrent subungual hyperkeratosis. When suspected, a potassium hydroxide examination, fungal culture and/or periodic acid-Schiff staining of the nail plate may be helpful.1,3,7,8
Subungual Melanoma
Recently, in an effort to aid in the differentiation of subungual hemorrhage and subungual melanoma as the cause of black nail pigmentation, a simple and fast method to detect blood pigment in nails was described. After distal free nail edge clipping and subungual scraping, the small fragments of dissolved nail plate are placed on a urinalysis reagent strip and a drop of water is added to soak both the sample and the strips. A green color change is indicative of a positive blood reaction.16 The presence of blood does not necessarily rule out subungual melanoma. Bleeding from the hyponychium or nail bed or both may inadvertently occur after vigorous nail clipping and subungual scraping; hence, the fragments of nail plate would demonstrate a positive blood reaction — even in the presence of a subungual melanoma. Also, a subungual melanoma might have spontaneously bled or the tumor may have been preceded by or only first recognized after trauma to the digit.5,17 The nail plate, without or with (indicating a positive Hutchinson’s sign) inclusion of the proximal nail fold, may be discolored secondary to a subungual melanoma. Epiluminescence microscopy with a dermatoscope may be helpful to differentiate melanoma from hemorrhage. However, a nail matrix and/or nail bed biopsy should be considered if a subungual melanoma is suspected.1,8
Pathology
Following a subungual hematoma, pathologic changes can be observed on light microscope examination of the nail plate and nail bed biopsy specimen. Large collections of homogenous eosinophilic and yellow-brown material are present either within (secondary to transepidermal elimination) and/or beneath the nail plate. The yellow-brown masses represent hemoglobin from the lysed red blood cells.18,19 The amorphous material can be stained brown with the benzidine stain that confirms the presence of hemoglobin; however, since benzidine has been identified as a carcinogen in humans, this stain is not routinely used in histopathology laboratories. The homogenous material stains blue-green with the patent blue V stain. Although this staining method is safe, the stain is not specific for hemoglobin; the nail plate and more keratinizing upper epidermal layers of the nail bed also stain blue-green. Since the amorphous material is hemoglobin, it does not react with stains that demonstrate iron that is deposited in tissue as hemosiderin, such as the prussian blue (Perls’) stain and the Turnbull’s blue stain.18,19
Treatment
The management of acute subungual hematoma focuses on removal of the collection of blood, which results not only in immediate relief of the digital pain but also minimizes any additional injury to the nail bed and nail matrix. Several interventional modalities have been described. These vary with regards to the approach and treatment used to reach the hematoma.
The subungual hematoma can usually be removed within the first 48 hours if it has not organized into a solid mass. The hematoma can be reached proximal to the nail plate by creating an exit route for the blood between the proximal nail fold and the proximal aspect of the nail plate using a toothpick or a flattened wooden applicator or a scalpel.20,21
Alternatively, the hematoma can be evacuated by allowing the blood to escape distally through a space created between the distal nail plate and the hyponychium using either a needle or scalpel blade.20,22
Another intervention, trephination, involves piercing the nail plate overlying the hematoma. Cautiously, slow and gentle pressure is applied to the terphine, which is placed perpendicular to the nail plate until blood exits from the surface of the through and through defect. Either a hot paper clip cautery held with a hemostat, a hot number 18 needle, a scapel blade used as a drill, a hand-held cautery unit or a carbon dioxide laser can be used to terphinate the nail plate. However, in a patient wearing artificial acrylic nails, which are flammable, trephination should not be performed using a hot cautery device.2,8,23-32
Relief of pain is generally immediate following the removal of the hematoma. The nail plate often remains intact following proximal or distal or terphinate decompression treatment of the blood associated with an acute subungual hematoma. However, if the hematoma involves more than 25% of the nail plate, subsequent onycholysis and shedding of the nail plate may occur.8
Avulsion of the nail plate may be necessary to evacuate the hematoma if the lesion is older than 2 days or if there has already been significant injury to the adjacent nail folds, as in this patient. Although systemic antibiotics are often not used following hematoma decompression treatment in which the nail plate remains intact, oral antibiotics to prevent infection are frequently prescribed following complete nail plate removal. One to 1½ years may be necessary for the growth of a new toenail based on an average growth rate of 1 mm per month and a nail length of 1.0 cm to 1.5 cm.2,8,20,33
Prevention
Prevention of subungual hematomas in runners has two components — appropriate footwear and nail hygiene. The running shoes should fit the mid foot snugly, yet comfortably, so that the distal foot is not forced into the toe box — especially when running down hill. Also, the toe box should be adequate so that the most distal nail does not pound into the tip of the shoe. In addition, proper trimming of the nails so that they are straight-cut (and not curved-cut) can help to prevent dystrophy and injury by ensuring equal distribution of forces.3,4,7
Resolution
The reported patient was experiencing severe discomfort and progressive soft tissue injury to the adjacent nail folds of his right great toe (Figure 2); the left second toe tenderness rapidly resolved spontaneously. Complete avulsion of the right great toenail was performed. Double-strength trimethoprim-sulfamethoxazole was prescribed twice daily for 10 days and the wound was cleaned three times each day followed by application of mupirocin 2% ointment. The left second toe was not treated; the distal onycholytic nail plate and associated underlying hematoma were cut back each month. Normal nail plates eventually grew on both toes.
Dr. Cohen is with the University of Houston Health Center, University of Houston, Houston, TX; the Department of Dermatology, The University of Texas; M.D. Anderson Cancer Center, Houston, TX; and the Department of Dermatology, University of Texas-Houston Medical School, Houston, TX.
Dr. Khachemoune, the Section Editor of Derm Dx, is with Department of Dermatology, State University of New York, Brooklyn, NY. Disclosure: The authors have no conflict of interest with any material presented in this column.
