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Histopathologic evaluation of nail clippings can result in a diagnosis of nail unit melanoma through the identification of melanocyte remnants. Histopathologic examination of nail clippings can also aid in triaging nail unit biopsy and assist in surgical planning. Nail clipping is a painless procedure, and the nail clippings must be at least 4 mm in length for adequate evaluation.
The authors suggest that dermatologists and dermatopathologists should increase the utilization of nail clipping histopathology in the evaluation of melanonychia to diagnose nail unit melanoma.
The diagnosis and management of longitudinal melanonychia are challenging for both dermatologists and dermatopathologists, as nail unit melanoma (NUM) is often a consideration. Definitive diagnosis often requires nail matrix sampling, however, this may be difficult to obtain for a variety of reasons. Nail clipping histopathology can provide extensive information in the evaluation of melanonychia with minimal discomfort for a patient, and little disruption to a physician’s clinic flow.
Pigmented lesion of the nail unit can be challenging both clinically and pathologically. The vast majority of pigmented lesions are benign. However, nail unit melanoma is in the differential and, given the high risk, sampling variability often presents a problem clinically.
This study from Philadelphia evaluated melanocytic remnants (MR) in nail clippings. This is a rapid office procedure for the evaluation of a melanocytic lesion, especially when patients are afraid of a possible dystrophy caused by sampling of the nail unit.
The group emphasizes the importance of clinical impression as a concerning feature leading to sampling. They also caution the interpretation of MR in children, given that the vast majority of lesions in children are benign. While immunohistochemistry may be of help, there is the possibility of false-negative immunohistochemical stains because of softening agents used.
This was a very helpful article, showing again that many things can be told from mere nail clippings as long as adequate sampling is done (4-mm nail clipping with perpendicular sections). It highlights an important tool that clinicians have, as many do not feel comfortable with nail unit sampling, and this allows one to get a rather accurate diagnosis, especially when a photograph and clinical concern are noted.