I am concerned about the image used in the Ortho Dx case regarding a subungual hematoma [“Ortho Dx: Would you remove this fingernail?”]. There are features in the image that suggest a diagnosis of melanoma, specifically, hyperpigmentation that involves the skin of the distal digit adjacent to the hyperpigmented streak and hyperpigmentation of the proximal nail fold (cuticle). These are not features of hematoma, but they are associated with melanoma.

This was a therapeutic and not a diagnostic case presentation—ie, we are told this is a subungual hematoma. But as a dermatologist, if I saw this patient, even with the history provided, I would want to do further examination of the hyperpigmented cutaneous areas by microscopy and likely obtain a biopsy of the nail unit.—Barbara M. Mathes, MD, FACP, Philadelphia

Continue Reading

These are letters from practitioners around the country who want to share their clinical problems and successes, observations and pearls with their colleagues. We invite you to participate. If you have a clinical pearl, submit it here.