Longitudinal erythronychia: Suggestions for evaluation and management
2010; Elsevier BV; Volume: 64; Issue: 1 Linguagem: Inglês
10.1016/j.jaad.2009.10.047
ISSN1097-6787
Autores Tópico(s)Infectious Diseases and Mycology
ResumoLongitudinal erythronychia is a frequent nail presentation with a limited differential diagnosis. This clinical entity may be divided into cases that involve one (localized) or multiple (polydactylous) nails. The different presentations have distinct differential diagnoses and workups yet often share a common pathogenesis. Localized longitudinal erythronychia most commonly represents onychopapilloma, yet malignancies may present identically. Therefore biopsy may be required. Polydactylous longitudinal erythronychia usually coincides with a regional or systemic cause. Occasionally, it may herald an important underlying disease. A thorough understanding of the pathogenesis, clinical presentations, and possible diagnoses is necessary for successful evaluation and management. Longitudinal erythronychia is a frequent nail presentation with a limited differential diagnosis. This clinical entity may be divided into cases that involve one (localized) or multiple (polydactylous) nails. The different presentations have distinct differential diagnoses and workups yet often share a common pathogenesis. Localized longitudinal erythronychia most commonly represents onychopapilloma, yet malignancies may present identically. Therefore biopsy may be required. Polydactylous longitudinal erythronychia usually coincides with a regional or systemic cause. Occasionally, it may herald an important underlying disease. A thorough understanding of the pathogenesis, clinical presentations, and possible diagnoses is necessary for successful evaluation and management. Capsule Summary•Longitudinal erythronychia is a common nail presentation, with a limited differential diagnosis.•When limited to one digit (localized longitudinal erythronychia), the etiology is usually neoplastic, with onychopapilloma being the most common diagnosis. However, glomus tumor, Bowen's disease, melanoma in situ, and basal cell carcinoma have all been reported in this presentation.•When identified on multiple digits (polydactylous longitudinal erythronychia), there is usually an underlying regional or systemic cause. The most common include lichen planus and Darier's disease. Other important, less common causes include systemic amyloidosis, graft-versus-host disease, and hemiplegia.•In certain circumstances, biopsy is indicated. A partial nail plate avulsion coupled with a longitudinal biopsy of matrix and bed is the recommended technique for diagnosis in most circumstances.Longitudinal erythronychia is a relatively common finding. For purposes of evaluation and management, longitudinal erythronychia can be divided into two groups, depending upon whether it involves one or multiple nails. Both groups, localized longitudinal erythronychia (LLE) and polydactylous longitudinal erythronychia (PLE), are associated with a limited differential diagnosis. LLE 1Baran R. Perrin C. Longitudinal erythronychia with distal subungual keratosis: onychopapilloma of the nail bed and Bowen's disease.Br J Dermatol. 2000; 143: 132-135Crossref PubMed Scopus (90) Google Scholar, 2de Berker D.A. Perrin C. Baran R. Localized longitudinal erythronychia: diagnostic significance and physical explanation.Arch Dermatol. 2004; 140: 1253-1257Crossref PubMed Scopus (59) Google Scholar may be caused by onychopapilloma, wart, warty dyskeratoma,3Baran R. Perrin C. Focal subungual warty dyskeratoma.Dermatology. 1997; 195: 278-280Crossref PubMed Scopus (30) Google Scholar glomus tumor, increased glomus bodies and other benign vascular proliferations,4Chamberlain A.J. Millard P.R. Pryce D.W. Dawber R.P. Acquired periungual arteriovenous tumour (cirsoid aneurysm).J Eur Acad Dermatol Venereol. 2005; 19: 255-256Crossref PubMed Scopus (6) Google Scholar a solitary lesion of lichen planus,5Richert B. Iorizzo M. Tosti A. Andre J. Nail bed lichen planus associated with onychopapilloma.Br J Dermatol. 2007; 156: 1071-1072Crossref PubMed Scopus (15) Google Scholar Bowen's disease,1Baran R. Perrin C. Longitudinal erythronychia with distal subungual keratosis: onychopapilloma of the nail bed and Bowen's disease.Br J Dermatol. 2000; 143: 132-135Crossref PubMed Scopus (90) Google Scholar, 2de Berker D.A. Perrin C. Baran R. Localized longitudinal erythronychia: diagnostic significance and physical explanation.Arch Dermatol. 2004; 140: 1253-1257Crossref PubMed Scopus (59) Google Scholar, 6Cogrel O. Beylot-Barry M. Doutre M.S. [Subungual squamous cell carcinoma revealed by longitudinal erythronychia].Ann Dermatol Venereol. 2008; 135 (French): 883-885Crossref PubMed Scopus (14) Google Scholar, 7Dalle S. Depape L. Phan A. Balme B. Ronger-Savle S. Thomas L. Squamous cell carcinoma of the nail apparatus: clinicopathological study of 35 cases.Br J Dermatol. 2007; 156: 871-874Crossref PubMed Scopus (107) Google Scholar melanoma in situ,8Harwood M. Telang G.H. Robinson-Bostom L. Jellinek N. Melanoma and squamous cell carcinoma on different nails of the same hand.J Am Acad Dermatol. 2008; 58: 323-326Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar and basal cell carcinoma9Gee B.C. Millard P.R. Dawber R.P. Onychopapilloma is not a distinct clinicopathological entity.Br J Dermatol. 2002; 146: 156-157Crossref PubMed Scopus (18) Google Scholar (Table I, Fig 1, Fig 2, Fig 3, Fig 4, Fig 5, Fig 6, Fig 7, Fig 8, Fig 9, Fig 10, Fig 11, Fig 12, Fig 13; Fig 1, Fig 2, Fig 3, Fig 4, Fig 7, Fig 8, Fig 9, 12 are available online at http://www.eblue.org). PLE has been associated most commonly with lichen planus10Baran R. Dawber R.P.R. Richert B. Physical signs.in: Baran R. Dawber R.P.R. De Berker D.A.R. Haneke E. Tosti A. Baran and Dawber's Diseases of the nails and their management. 3rd. Blackwell Science, Malden, MA2001: 48-103Crossref Scopus (16) Google Scholar and Darier's disease11Zaias N. Ackerman A.B. The nail in Darier-White disease.Arch Dermatol. 1973; 107: 193-199Crossref PubMed Scopus (77) Google Scholar and occasionally with systemic amyloidosis,10Baran R. Dawber R.P.R. Richert B. Physical signs.in: Baran R. Dawber R.P.R. De Berker D.A.R. Haneke E. Tosti A. Baran and Dawber's Diseases of the nails and their management. 3rd. Blackwell Science, Malden, MA2001: 48-103Crossref Scopus (16) Google Scholar, 12Derrick E.K. Price M.L. Primary systemic amyloid with nail dystrophy.J R Soc Med. 1995; 88: 290P-291PPubMed Google Scholar hemiplegia,13Siragusa M. Schepis C. Cosentino F.I. Spada R.S. Toscano G. Ferri R. Nail pathology in patients with hemiplegia.Br J Dermatol. 2001; 144: 557-560Crossref PubMed Scopus (28) Google Scholar graft-versus-host disease,14Liddle B.J. Cowan M.A. Lichen planus-like eruption and nail changes in a patient with graft-versus-host disease.Br J Dermatol. 1990; 122: 841-843Crossref PubMed Scopus (22) Google Scholar, 15Palencia S.I. Rodriguez-Peralto J.L. Castano E. Vanaclocha F. Iglesias L. Lichenoid nail changes as sole external manifestation of graft vs. host disease.Int J Dermatol. 2002; 41: 44-45Crossref PubMed Scopus (23) Google Scholar acantholytic epidermolysis bullosa,16Hoffman M.D. Fleming M.G. Pearson R.W. Acantholytic epidermolysis bullosa.Arch Dermatol. 1995; 131: 586-589Crossref PubMed Scopus (17) Google Scholar or with no association17Baran R. Dawber R.P. Perrin C. Drape J.L. Idiopathic polydactylous longitudinal erythronychia: a newly described entity.Br J Dermatol. 2006; 155: 219-221Crossref PubMed Scopus (17) Google Scholar (Table II, Fig 14, Fig 15, Fig 16, Fig 17 [Fig 14, Fig 15, Fig 16 available online at www.eblue.org]).Table IDifferential diagnosis of LLEMore common Onychopapilloma Glomus tumor Bowen's disease WartLess common Wart Warty dyskeratoma Benign vascular proliferation (increased glomus bodies, cirsoid aneurysm) Lichen planus (isolated lesion) Nail melanoma Basal cell carcinomaLLE, Localized longitudinal erythronychia. Open table in a new tab Fig 2Onychopapilloma presenting as LLE and demonstrating distal onycholysis and hyperkeratosis of the distal nail bed and hyponychium.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3Onychopapilloma presenting as wedge-shaped LLE and demonstrating nail bed splinter hemorrhages and distal onycholysis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 4Onychopapilloma presenting as a fine band of LLE.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 5Onychopapilloma presenting as LLE with a tear-drop-shaped origin in the lunula, and distal splinter hemorrhages (A). B, Direct dermatoscopy using water-soluble jelly shows splinter hemorrhages and a pink lucency in the lunula.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 6Onychopapilloma presenting as LLE (A and B). C, Direct dermatoscopy using water-soluble jelly shows more subtle clinical features, splinter hemorrhages and V-shaped distal onycholysis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 7A, Poorly defined band of LLE mimicking longitudinal melanonychia. B, Dermatoscopy highlights erythronychia and splinter hemorrhages. Histopathologic examination showed onychopapilloma.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 8A and B, Onychopapilloma presenting as LLE. C, Marked telangiectasia on lunula highlighted by dermatoscopy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 9A, Onychopapilloma presenting with two bands of LLE and marked unilateral onycholysis. B, Dermatoscopy demonstrates marked funnel-shaped red dyschromia and telangiectasia on the lunula, a feature not apparent on direct examination or with a 7× loupe.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 10A, An unusual case of an onychopapilloma presenting as LLE on the great toe with a thin band of distal true leukonychia. B and C, Trap-door avulsion shows red discoloration of the distal matrix and a subtle longitudinal ridge of nail bed.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 11Glomus tumor presenting as LLE, with distal nail plate splitting and onycholysis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 12Amelanotic melanoma in situ presenting as LLE. Note prominent distal onycholysis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 13A, Preoperative LLE, demonstrating a narrow red band, distal onycholysis, and splinter hemorrhages. B, After a longitudinal partial nail plate avulsion; band is visualized with splinter hemorrhages. C, After a narrow longitudinal excision. D, Short-term (10-week) follow-up, without obvious residual erythronychia.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Table IIDifferential diagnosis of PLELichen planusDarier diseasePrimary amyloidosisGraft-versus-host diseaseHemiplegiaAcantholytic epidermolysis bullosaIdiopathicPLE, Polydactylous longitudinal erythronychia. Open table in a new tab Fig 14Systemic amyloidosis with PLE, splinter hemorrhages, onychorrhexis, onychoschizia, hyperkeratosis of the cuticle, and a flaccid vesicle on dorsal aspect of one finger.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 15Nails with classic Darier's disease, with “candy-cane” PLE, distal onycholysis, splinter hemorrhages, and hyperkeratosis of hyponychium distal to red bands.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 16Nail lichen planus, with PLE, nail plate thinning, onychorrhexis, and mild onycholysis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 17Graft-versus-host disease with PLE, distal onycholysis, nail plate atrophy, and onychorrhexis.(Courtesy of Bianca Maria Piraccini, MD.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)de Berker, Perrin, and Baran2de Berker D.A. Perrin C. Baran R. Localized longitudinal erythronychia: diagnostic significance and physical explanation.Arch Dermatol. 2004; 140: 1253-1257Crossref PubMed Scopus (59) Google Scholar have proposed a pathogenesis that unifies most of the different diagnoses: a disease process limited to the distal matrix (either inflammatory, neoplastic, space occupying, or nonspecific), results in the production of a thinned longitudinal strip of ventral plate. The opposing nail bed swells to fill the concavity in the ventral plate. This longitudinal section of nail bed is compressed by the normal nail plate at the margins. This lateral pressure leads to an engorged nail bed trapped in the ventral groove, predisposed to splinter hemorrhages. The thinned plate is more transparent, further enhancing any underlying erythema (Fig 18). As this plate grows distally and reaches the free margin, it is subject to trauma from activities of daily living, fragments more easily, resulting in distal chipping and onycholysis. The underlying hyponychium reacts with secondary inflammation, hyperkeratosis, and occasional giant cell formation.Fig 18Pathogenesis of longitudinal erythronychia, as proposed by de Berker. Distal matrix disease process results in production of a thinned ventral nail plate. Nail bed swells to fill the concave nail plate, is pinched by the sides. causing splinter hemorrhages, and cracks and splits distally with activities of daily living (ADL). Secondary reactive hyperkeratosis of distal nail bed and hyponychium results.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Clinically, cases show some or all of the following: longitudinal pink-red nail discoloration, often associated with or composed entirely of splinter hemorrhages; a lucency in the distal matrix (visualized as the lunula on the thumbs and index fingers in most patients); distal V-shaped chipping, splitting, and onycholysis of the nail plate at the free edge, with reactive distal nail bed and hyponychial hyperkeratosis (see Fig 1, Fig 2, Fig 3, Fig 4 [available online at http://www.eblue.org) .These changes are appreciated upon direct examination but amplified with a magnifier, 7× loupe, or dermatoscopy (see Fig 5, Fig 6, Fig 7, Fig 8, Fig 9, Fig 10 [Fig 7, Fig 8, Fig 9 available online]). Dermatoscopy nicely highlights the splinter hemorrhages observed in most cases. In addition, some cases remain ambiguous until examined by dermoscopy (see Fig 7; available online) or when examining the nail plate from several angles.Given the disparate differential diagnoses, the discussion of evaluation and management of LLE and PLE is addressed separately. As a general rule, however, the workup of LLE focuses on the possibility of a local neoplastic process, whereas that of PLE is centered on a search for underlying regional or systemic causes.Localized longitudinal erythronychiaLLE most commonly presents on the thumbs in middle age,2de Berker D.A. Perrin C. Baran R. Localized longitudinal erythronychia: diagnostic significance and physical explanation.Arch Dermatol. 2004; 140: 1253-1257Crossref PubMed Scopus (59) Google Scholar although any digit may be affected. Involvement of the toenails is unusual (see Fig 10). Symptoms range from none to pain and tenderness. Patients commonly complain of catching the onycholytic split free edge on clothes and fabrics.The most common cause of LLE is onychopapilloma1Baran R. Perrin C. Longitudinal erythronychia with distal subungual keratosis: onychopapilloma of the nail bed and Bowen's disease.Br J Dermatol. 2000; 143: 132-135Crossref PubMed Scopus (90) Google Scholar, 2de Berker D.A. Perrin C. Baran R. Localized longitudinal erythronychia: diagnostic significance and physical explanation.Arch Dermatol. 2004; 140: 1253-1257Crossref PubMed Scopus (59) Google Scholar, 18Baran R. Perrin C. Localized multinucleate distal subungual keratosis.Br J Dermatol. 1995; 133: 77-82Crossref PubMed Scopus (43) Google Scholar (Table I, see Fig 1, Fig 2, Fig 3, Fig 4, Fig 5, Fig 6, Fig 7, Fig 8, Fig 9, Fig 10 [Fig 1, Fig 2, Fig 3, Fig 4 and Fig 7, Fig 8, Fig 9 available online]). Onychopapilloma is an idiopathic benign tumor, and there is some debate about its etiology and pathogenesis.2de Berker D.A. Perrin C. Baran R. Localized longitudinal erythronychia: diagnostic significance and physical explanation.Arch Dermatol. 2004; 140: 1253-1257Crossref PubMed Scopus (59) Google Scholar, 9Gee B.C. Millard P.R. Dawber R.P. Onychopapilloma is not a distinct clinicopathological entity.Br J Dermatol. 2002; 146: 156-157Crossref PubMed Scopus (18) Google Scholar It presents as a classic band of LLE, often with prominent distal hyperkeratosis that may resemble a distinct papule at the hyponychium, seemingly emanating from the distal nail bed (see Fig 2 [available online]). Rarely, two bands may be present in one digit1Baran R. Perrin C. Longitudinal erythronychia with distal subungual keratosis: onychopapilloma of the nail bed and Bowen's disease.Br J Dermatol. 2000; 143: 132-135Crossref PubMed Scopus (90) Google Scholar (see Fig 9 [available online]). Dermatoscopic findings occasionally highlight pink-red erythema of the lunula criss-crossed with minute telangiectases (see Fig 8, Fig 9 [available online]). I have also observed a single case of onychopapilloma presenting as longitudinal leukonychia.19Criscione V. Telang G. Jellinek N.J. Onychopapilloma presenting as longitudinal leukonychia.J Am Acad Dermatol. 2010; 63: 541-542Abstract Full Text Full Text PDF PubMed Scopus (31) Google ScholarUpon total or partial nail plate avulsion, an onychopapilloma shows variable, subtle pink erythematous swelling in the distal matrix, a longitudinal ridge in the nail bed, and distal bed hyperkeratosis (see Fig 10, B and C). Histologically, it is characterized by variable and nonspecific matrix findings but diagnostic nail bed changes: there is prominent nail bed acanthosis and papillomatosis, visualized most clearly in transverse sections. The upper cell layers in the nail bed epithelium exhibit abundant eosinophilic cytoplasm closely resembling that of the nail matrix keratogenous zone, thought to indicate matrix metaplasia of the nail bed epithelium (Fig 19). In the first series reported by Baran and Perrin,18Baran R. Perrin C. Localized multinucleate distal subungual keratosis.Br J Dermatol. 1995; 133: 77-82Crossref PubMed Scopus (43) Google Scholar multinucleated cells were observed in the hyponychium in 4 of 4 cases. However, a subsequent report noted multinucleate cells in only 2 of the 14 cases; it is likely that they represent a nonspecific histologic sign.1Baran R. Perrin C. Longitudinal erythronychia with distal subungual keratosis: onychopapilloma of the nail bed and Bowen's disease.Br J Dermatol. 2000; 143: 132-135Crossref PubMed Scopus (90) Google Scholar, 2de Berker D.A. Perrin C. Baran R. Localized longitudinal erythronychia: diagnostic significance and physical explanation.Arch Dermatol. 2004; 140: 1253-1257Crossref PubMed Scopus (59) Google ScholarFig 19Nail bed biopsy in setting of onychopapilloma. Epithelium shows maturation with development of keratogenous zone, indicative of matrix metaplasia of nail bed. This is a histologic hallmark of onychopapilloma.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Other causes of LLE range from the more common and benign (wart, glomus tumor) to the rare and malignant. Of the malignancies, Bowen's disease is by far the most frequently observed. However, there is no published or widely accepted algorithm for the workup of LLE.When a patient presents with LLE, a detailed history and physical examination can sometimes narrow the differential diagnosis. Any history of a painful nail, particularly exacerbated by cold, associated with point tenderness and radiation of pain up the finger, hand, and arm, are keys to the diagnosis of glomus tumor. In this instance, imaging is unnecessary (classic presentation by history and exam, with symptoms that require intervention) and the patient can be taken to surgery for exploration and excision. Occasionally the presentation is more subtle and physical examination findings and bedside maneuvers are nonspecific. When the clinical suspicion for glomus tumor remains high, radiologic imaging with magnetic resonance or ultrasound, or even occasionally plain film x-ray, may be diagnostic.20Al-Qattan M.M. Al-Namla A. Al-Thunayan A. Al-Subhi F. El-Shayeb A.F. Magnetic resonance imaging in the diagnosis of glomus tumours of the hand.J Hand Surg Br. 2005; 30: 535-540PubMed Google Scholar, 21Matsunaga A. Ochiai T. Abe I. Kawamura A. Muto R. Tomita Y. et al.Subungual glomus tumour: evaluation of ultrasound imaging in preoperative assessment.Eur J Dermatol. 2007; 17: 67-69PubMed Google Scholar, 22Takemura N. Fujii N. Tanaka T. Subungual glomus tumor diagnosis based on imaging.J Dermatol. 2006; 33: 389-393Crossref PubMed Scopus (46) Google Scholar, 23Koc O. Kivrak A.S. Paksoy Y. Subungual glomus tumour: magnetic resonance imaging findings.Australas Radiol. 2007; : B107-B109Crossref PubMed Scopus (19) Google Scholar, 24Chen S.H. Chen Y.L. Cheng M.H. Yeow K.M. Chen H.C. Wei F.C. The use of ultrasonography in preoperative localization of digital glomus tumors.Plast Reconstr Surg. 2003; 112 (discussion 120): 115-119Crossref PubMed Scopus (76) Google ScholarSubungual warts and warty dyskeratomas are usually more subtle clinical diagnoses. A history of periungual warts or immunosuppression may lead the clinician to suspect human papillomavirus as the cause. Other unusual and variably nonspecific diagnoses have been observed upon biopsy of LLE, including a range of benign vascular proliferations. As one possible confounder, a single suspected occurrence of onychopapilloma has been reported, simulated by a solitary lesion of nail lichen planus.5Richert B. Iorizzo M. Tosti A. Andre J. Nail bed lichen planus associated with onychopapilloma.Br J Dermatol. 2007; 156: 1071-1072Crossref PubMed Scopus (15) Google Scholar In most cases, however, there are no history or physical examination findings that point to a particular diagnosis, or the finding of LLE is completely incidental. In such instances, it is important to assess whether the lesion is stable or evolving. Any evolving or new band of LLE usually indicates that a biopsy should be considered. Any stable band of LLE, documented by a good historian or repeated examinations without change, must at the very least be followed up as a lesion of indeterminate significance, as one would follow up an unusual pigmented lesion presumed, but unproven, to be benign. In my practice, patients with such lesions of LLE are often followed up at regular intervals, are told to watch the lesion for any change, and to return sooner if changes occur.One proposed algorithm for this evaluation is found as Fig 20.Fig 20Proposed algorithm for evaluation of LLE.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Polydactylous longitudinal erythronychiaPLE commonly presents in adulthood, if only because the associated diseases are unusual in children. Like LLE, PLE may be an incidental finding or presenting complaint (see Fig 14, Fig 15, Fig 16, Fig 17 [Fig 14, Fig 15, Fig 16 available online]). In some circumstances, such as underlying hemiplegia, multiple myeloma, or Darier's disease, the nail manifestation is an obvious associated finding of another disease. In certain cases, however, the nail changes constitute the sole clinical manifestation, without signs of an underlying disease. In these circumstances, a workup for etiology is advisable. In Darier's disease, which can present rarely as isolated nail disease, there is the possibility of transmitting the autosomal dominant genodermatosis to subsequent generations who may develop more generalized signs of disease. PLE in lichen planus may predate other cutaneous, mucosal, hair, or progressive scarring nail disease. PLE may also trigger a workup for hematologic malignancy if the diagnosis of amyloidosis is made.One proposed algorithm for this evaluation is found as Fig 21.Fig 21Proposed algorithm for evaluation of PLE.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Biopsy techniques for longitudinal erythronychiaBecause the relevant pathology involves the distal matrix and commonly extends onto the nail bed, a longitudinal biopsy is perfectly suited.25Zaias N. The longitudinal nail biopsy.J Invest Dermatol. 1967; 49: 406-408PubMed Google Scholar, 26Collins S.C. Jellinek N.J. Matrix biopsy of longitudinal melanonychia and longitudinal erythronychia: a step-by-step approach.Cosmet Dermatol. 2009; 22: 19-26Google Scholar A longitudinal fusiform biopsy is performed, starting at the mid to distal matrix, extending through the bed to the hyponychium, and can be executed after one of several nail avulsion techniques2de Berker D.A. Perrin C. Baran R. Localized longitudinal erythronychia: diagnostic significance and physical explanation.Arch Dermatol. 2004; 140: 1253-1257Crossref PubMed Scopus (59) Google Scholar, 26Collins S.C. Jellinek N.J. Matrix biopsy of longitudinal melanonychia and longitudinal erythronychia: a step-by-step approach.Cosmet Dermatol. 2009; 22: 19-26Google Scholar, 27Collins S.C. Cordova K. Jellinek N.J. Alternatives to complete nail plate avulsion.J Am Acad Dermatol. 2008; 59: 619-626Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar (see Fig 10, Fig 13) This biopsy technique may or may not require suturing to repair the distal matrix. The distal half of the matrix produces only the ventral 20% of the nail plate28De Berker D. Mawhinney B. Sviland L. Quantification of regional matrix nail production.Br J Dermatol. 1996; 134: 1083-1086Crossref PubMed Scopus (64) Google Scholar and may not result in a split nail if left to heal by second intention. Nevertheless, the likelihood of this outcome can be minimized through wide undermining and side-to-side suturing of the matrix with absorbable suture, or by performing one of several local matrix sliding flaps.29Abimelec P. Dumontier C. Basic and advanced nail surgery (Part 1: Principles and Techniques).in: Scher R.K. Daniel C.R.I.I.I. Nails: diagnosis, therapy, surgery. Elsevier Saunders, Philadelphia2005: 265-289Crossref Scopus (16) Google Scholar The nail bed may heal by second intention with little risk of postoperative dystrophy.The longitudinal specimen is excised at the level of periosteum and sectioned according to the specific instructions of the surgeon. Longitudinal processing demonstrates contiguous pathology in this setting and in most cases is preferred by the pathologists with whom I work. Transverse sectioni
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