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- Presentation
Inflammatory and Neoplastic Nail Disease in Patients of Color
Description
The talk reviewed inflammatory and neoplastic nail disease in patients of color, emphasizing that these conditions are underreported and often present differently than in lighter skin. In a systematic review of inflammatory nail disease, nail psoriasis was the most common diagnosis, with pitting as the leading feature, but erythema and salmon patches were often less visible or absent; instead, hyperpigmentation and longitudinal melanonychia were common. Lichen planus also frequently showed onychorrhexis and melanonychia, with nail bed and fold erythema/swelling more apparent in some cases. Onychomycosis may also be associated with melanonychia due to inflammation or melanocyte activation. For neoplastic disease, the speaker highlighted that longitudinal melanonychia, longitudinal erythronychia/leptonychia, and longitudinal pachyonychia each have important differentials, including onychopapilloma, onychomatricoma, and squamous cell carcinoma. In their biopsy cohort, melanocyte activation was the most common cause of melanonychia, but SCC was also present; similar concerns were noted for leptonychia and pachyonychia. A literature review of nail SCC in darker phototypes found a high rate of invasive disease and amputations. For nail unit melanoma, recent data suggested melanoma was associated with multiple colors, irregular band thickness, and brown-black coloration, but not necessarily greater percentage of nail plate involvement, implying that standard warning signs may not translate the same way in patients of color.
View moreConclusions
- Inflammatory nail disease in skin of color often presents with less visible erythema and more prominent hyperpigmentation or longitudinal melanonychia than in lighter skin.
- Nail psoriasis remains the most commonly reported inflammatory nail disorder in patients of color, but classic salmon patches and nail bed redness are frequently subtle or absent.
- Lichen planus in skin of color commonly shows melanonychia and nail plate abnormalities, with nail fold swelling and nail bed erythema occurring more often than in psoriasis.
- Longitudinal melanonychia is a frequent reaction pattern across both inflammatory disease and onychomycosis in darker phototypes, likely reflecting melanocyte activation.
- Benign nail matrix tumors such as onychopapilloma and onychomatricoma often present with associated longitudinal melanonychia in darker skin types, so pigment does not exclude benign disease.
- Squamous cell carcinoma of the nail unit should be considered high on the differential for monodactylous longitudinal nail changes because it can mimic benign lesions and may present with pigmentation, thinning, or thickening.
- Nail SCC in skin of color appears to be diagnosed late and is often invasive at presentation, with a substantial proportion of reported cases requiring amputation.
- For nail unit melanoma in skin of color, multiple colors, irregular band thickness, and brown-to-black pigmentation are concerning features, whereas percent nail plate involvement is less useful for distinguishing malignant from benign lesions.
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