Spot Diagnosis

Black linear nail lesion in a preschooler

Carolina Fraga1, Alexandra Azevedo2, Fábio Barroso3
1Pediatrics Department, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário de Santo António, Porto, Portugal, 2Dermatology Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal, 3Pediatrics Department, Centro Hospitalar do Tâmega e Sousa, Penafiel, Portugal

Address for Correspondence: Carolina Fraga, Largo da Maternidade de Júlio Dinis 45, 4050-651 Porto, Portugal.
Email: carolinamoraesfraga@gmail.com
Keywords : Melanocytes, Child, Nail alterations
Question :
A four-year-old Caucasian female was being observed in emergency department for an unrelated complain (dysuria), when her mother reported the presence of a black linear lesion on her right thumb nail. This was present for two years and there was no history of previous trauma or recent medication when it was initially noted. It kept the same characteristics throughout time despite the nail's growth. Her father displayed a similar lesion.
On physical exam she presented a narrow black linear pigmentation along the entire length of the nail of the first finger of the right hand (Figure 1A). There were no other lesions on the remaining hand and feet nails or in the skin.
The child was referred to Dermatology where longitudinal melanonychia (LM) was diagnosed. Since the lesion was stable, conservative approach was adopted. Following two years of dermoscopic surveillance, spontaneously partial regression of the lesion was confirmed with lightening of the proximal half. (Figure 1B).

Figure 1. Dermatoscopic images: A - Pigmented band along the entire length of the nail of the right thumb without nail dystrophy at diagnosis; B - the same lesion two years later, narrower and lighter proximally.
<b>Figure 1.</b> Dermatoscopic images: A - Pigmented band along the entire length of the nail of the right thumb without nail dystrophy at diagnosis; B - the same lesion two years later, narrower and lighter proximally.


What is the diagnosis?

Discussion :
LM is a dark pigmentation of the nail plate that results from either activation or hyperplasia of melanocytes in the nail matrix. It is more prevalent in darked-skin individuals, mostly in adulthood, being rare in children particularly Caucasian. Familial occurrence with an early age of onset was described only exceptionally.1
Although it may rarely be secondary to subungual melanoma, it is typically benign in children. Clinical features that raise concern for melanoma include rapid evolution, changing pigmentation or shape, color heterogenicity, blurred lateral borders, pigment band greater than 3 mm and associated nail dystrophy. Hutchinson sign (periungual pigmentation) is a hallmark for subungual melanoma in adults but in children it may be present in benign melanonychia.2 Most recent publications support a wait-and-see strategy in pediatric LM with clinical and dermoscopic follow-up. Biopsy is indicated in the presence of concerning signs.1,3

References :
  1. Leung AKC, Lam JM, Leong KF, Sergi CM. Melanonychia striata: clarifying behind the Black Curtain. A review on clinical evaluation and management of the 21st century. Int J Dermatol. 2019 Nov;58(11):1239-1245. doi: 10.1111/ijd.14464. Epub 2019 Apr 21. PMID: 31006857.
  2. Cooper C, Arva NC, Lee C, Yélamos O, Obregon R, Sholl LM, Wagner A, Shen L, Guitart J, Gerami P. A clinical, histopathologic, and outcome study of melanonychia striata in childhood. J Am Acad Dermatol. 2015 May;72(5):773-9. doi: 10.1016/j.jaad.2015.01.010. Epub 2015 Mar 9. PMID: 25766363.
  3. Morato IB, Gontijo JRV, Tavares GT, Bittencourt FV. Longitudinal melanonychia in childhood: a great challenge. An Bras Dermatol. 2022 Jul-Aug;97(4):516-519. doi: 10.1016/j.abd.2021.02.012. Epub 2022 Jun 9. PMID: 35691736; PMCID: PMC9263629.

Correct Answers : yes  100%

Last Shown : Apr 2026
 
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