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- Presentation
Diagnostic Uses of Nail Clippings in Nail Disorders
Description
The talk highlights how nail clippings can be diagnostically useful far beyond onychomycosis. In nail psoriasis, clippings may show ventral hyperkeratosis, parakeratosis, neutrophilic inflammation, pitting, and hemorrhage; when findings are subtle or inconclusive, a nail bed or subungual biopsy may still be needed. Nail clippings can also help identify onychomatricoma and onychocytic matricoma by revealing characteristic cavities, keratinized epithelial projections, and associated blood vessels, sometimes guiding diagnosis before excision. They may detect atypical perikeratosis concerning for nail unit squamous cell carcinoma, and can support diagnosis of onychopapilloma. A major warning sign is melanocyte remnants in adult nail clippings, which are strongly concerning for nail unit melanoma, though similar findings can be benign in children. Clippings can also aid surgical planning for melanonychia by localizing pigment origin, and may even show mixed pathology such as fungal elements plus melanoma in situ. Overall, nail clippings are presented as a low-cost, high-yield tool that can provide important histopathologic clues across multiple nail disorders.
View moreConclusions
- Nail clippings can substantially improve diagnostic accuracy for a range of nail disorders, especially when interpreted with clinicopathologic correlation.
- For nail psoriasis, nail clipping may show characteristic changes such as hyperkeratosis, pitting, and hemorrhage, but inconclusive cases often still require a nail bed or subungual biopsy.
- Subungual hematoma can be confirmed histologically from nail clipping, and blood-specific stains such as diaminobenzidine can help prove acute hemorrhage.
- Nail clipping can reveal diagnostic cavities and epithelial patterns that support onychomatricoma and onychocytic matricoma / longitudinal subungual acanthoma.
- Atypical parakeratosis on nail clipping can raise concern for nail unit squamous cell carcinoma in situ.
- Nail clipping can help identify onychopapilloma, including its characteristic hyperkeratotic and longitudinal changes, and may even suggest malignant variants, though evidence remains limited.
- Melanocyte remnants or pigmentation within the nail plate on an adult nail clipping are worrisome for nail unit melanoma, although similar findings can be benign in children.
- Nail clipping histopathology can assist with surgical planning in melanonychia by localizing pigment and suggesting its matrix origin.
- Because nail clipping can sometimes miss important pathology, definitive diagnosis may still depend on additional biopsy when suspicion remains high.
- Werner B, Fonseca GP, Seidel G. Microscopic nail clipping findings in patients with psoriasis. Am J Dermatopathol. 2015 Jun;37(6):429-39.#10.1097/dad.0000000000000197
- Bertanha et al. Journal of the European Academy of Dermatology and Venereology. 2025. PMID provided on slide.
- Miteva M, de Farias DC, Zaias M, Romaneli P, Tosti A. Nail clipping diagnosis of onychomatricoma. Arch Dermatol. 2011 Sep;147(9):1117-8.#10.1001/archdermatol.2011.240
- Rodriguez O, Elenitsas R, Jiang AJ, Abbott J, Rubin AI. Journal of Cutaneous Pathology. 2023. Nail clipping histopathology in melanonychia.