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- Presentation
Nail Clippings in Diagnosing Fungal Infections, Psoriasis, Hematoma, Tumors, and Melanoma
Description
The speaker argues that nail clippings can benefit nearly every nail patient by providing rapid, useful diagnostic information across many conditions. For onychomycosis, nail clippings with PAS staining are highlighted as highly sensitive for fungal detection, often outperforming culture or direct microscopy, and confirming infection before oral antifungal therapy is emphasized as a Choosing Wisely recommendation. The talk also reviews psoriasis, where clippings may show hyperkeratosis, parakeratosis, neutrophils, pitting, and hemorrhage, though some cases still require additional sampling such as nail bed biopsy. Subungual hematoma can be recognized by hemorrhage patterns and stains like diaminobenzidine or GLUT1. Nail clippings may help identify nail tumors such as onychomatricoma and related lesions by revealing characteristic holes and epithelial markers, with hole size potentially helping distinguish tumor types. Finally, the speaker discusses nail unit melanoma and melanocytic lesions, noting that clippings can reveal melanocytes or remnants and may aid triage of longitudinal melanonychia, especially when patients decline biopsy. Overall, the lecture stresses that nail clipping pathology is a practical tool for diagnosing infections, inflammatory disease, hemorrhage, tumors, and melanoma, and that mixed findings are common, so one diagnosis does not exclude another.
View moreConclusions
- Nail clippings can substantially improve diagnostic accuracy across a wide range of nail disorders and should be considered in many patients.
- For suspected onychomycosis, nail clipping with PAS staining is more sensitive than culture or direct microscopy alone, and combined methods are best when confirmation is needed before oral antifungal treatment.
- Nail clipping can show supportive histologic features of nail psoriasis, but it is often insufficient by itself and some cases require additional sampling such as nail bed biopsy.
- Nail clippings can help diagnose subungual hematoma by demonstrating hemorrhage, including with special stains that highlight acute blood products.
- Nail clipping is a useful diagnostic tool for onychomatricoma, where the size and pattern of holes in the nail plate can point to the tumor.
- Nail clipping can reveal melanocyte remnants or suspicious pigmentation that may triage patients toward evaluation for nail unit melanoma.
- A benign nail clipping result does not exclude a second concurrent process, since onychomycosis and other nail tumors can coexist.
- Overall, nail clipping is best viewed as a rapid, low-burden first-line test that can guide treatment decisions and determine when more invasive biopsy is still necessary.
- Wilsmann-Theis D, et al. Comparison of sensitivities of routine methods for diagnosis of onychomycosis. Journal of the European Academy of Dermatology and Venereology. 2011.
- 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 L, Di Chiacchio NG, Di Chiacchio N, Cintra ML. Nail clipping may not be sufficient to corroborate the diagnosis of psoriasis. J Eur Acad Dermatol Venereol. 2025 May;39(5):e427-e429. doi: 10.1111/jdv.20414. Epub 2024 Nov 5. PMID: 39498978.#10.1111/jdv.20414
- Miteva M, de Farias DC, Zala N, Romanelli P, Tosti A. Nail clipping diagnosis of onychomatricoma. Arch Dermatol. 2011 Sep;147(9):1117-8.#10.1001/archdermatol.2011.240
- Rodriguez A, Elenitsas R, Jiang SB, Abbott D, Rubin AI. Nail unit dermatoses with clinically apparent melanonychia which show findings on nail clipping histopathology.