Challenge of the Week / Hand & Wrist / 04.17.20

A 45-year-old male patient presents with a painless 5-mm dark stripe under his fingernail that he noticed about 6 months ago. He denies trauma to the area and states that recently, the stripe has started to grow proximally just past the cuticle. Radiographs are unremarkable. Which of the following is the next step in management?
  • Oral and topical antifungal treatment
  • Antifungal treatment would be indicated for onychomycosis. The patient here presents with signs concerning for melanoma.

  • Distal interphalangeal amputation
  • While amputation is the correct management of a melanoma in this area, a diagnosis is needed prior to definitive treatment.

  • Nail removal and biopsy
  • In a patient with a wide melanonychia and extension to the proximal skin (Hutchinson sign), concern should be raised for melanoma. A biopsy would be the appropriate diagnostic step.

  • Nail removal and silver nitrate application
  • Silver nitrate application will not aid in obtaining a definitive diagnosis. It is more appropriately used for treatment of a pyogenic granuloma.

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