Non Melanocytic Pigment Abnormalities

  • Molly HinshawEmail author


Pigmentary disorders of the nails are frequent diagnostic and therapeutic challenges. Diagnostic challenges exist because physical examination findings do not always distinguish between non-melanocytic and melanocytic disorders. Lesions may evolve over time and early lesions may not yet have features definitively diagnostic. The condition frequently comes to medical attention with concern for melanoma. Therefore, of primary importance during the physical examination is to determine whether the pigmentary disorder is caused by too much melanin (melanocyte activation) or by an increased number of melanocytes (e.g. nevi, melanoma). If this distinction cannot be made and a biopsy is necessary, then one must be aware of and plan for intraoperative and postoperative issues that will determine whether or not an adequate diagnosis can be made. These include adequate sampling by the surgeon and interpretation by the dermatopathologist. In this chapter, a systematic approach to the physical examination and subsequent decision-making will be discussed as means by which to distinguish non-melanocytic from melanocytic causes of nail pigmentation.


Nail pigmentation Hyperpigmentation Melanonychia Melanonychia striata Melanocyte activation Pseudo-Hutchinson’s sign Pigmented fungus Trauma Talon noire Nail Biopsy 

Supplementary material

978-3-319-65649-6_19_MOESM1_ESM.pdf (23 kb)
Patient Handout (PDF 22 kb)


  1. 1.
    Andre J, Lateur N. Pigmented nail disorders. Dermatol Clin. 2006;24(3):329–39.PubMedGoogle Scholar
  2. 2.
    Braun RP, Baran R, Le Gal FA, Dalle S, Ronger S, Pandolfi R, et al. Diagnosis and management of nail pigmentations. J Am Acad Dermatol. 2007;56(5):835–47.PubMedGoogle Scholar
  3. 3.
    Di Chiacchio N, Ruben BS, Loureiro WR. Longitudinal melanonychias. Clin Dermatol. 2013;31(5):594–601.PubMedGoogle Scholar
  4. 4.
    Jefferson J, Rich P. Melanonychia. Dermatol Res Pract. 2012;2012:952186.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Tosti A, Piraccini BM, de Farias DC. Dealing with melanonychia. Semin Cutan Med Surg. 2009;28(1):49–54.PubMedGoogle Scholar
  6. 6.
    Mendiratta V, Jain A. Nail dyschromias. Indian J Dermatol Venereol Leprol. 2011;77(6):652–8.PubMedGoogle Scholar
  7. 7.
    Di Chiacchio ND, Farias DC, Piraccini BM, Hirata SH, Richert B, Zaiac M, et al. Consensus on melanonychia nail plate dermoscopy. An Bras Dermatol. 2013;88(2):309–13.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Haenssle HA, Blum A, Hofmann-Wellenhof R, Kreusch J, Stolz W, Argenziano G, et al. When all you have is a dermatoscope- start looking at the nails. Dermatol Pract Concept. 2014;4(4):11–20.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Mun JH, Kim GW, Jwa SW, Song M, Kim HS, Ko HC, et al. Dermoscopy of subungual haemorrhage: its usefulness in differential diagnosis from nail-unit melanoma. Br J Dermatol. 2013;168(6):1224–9.PubMedGoogle Scholar
  10. 10.
    Ronger S, Touzet S, Ligeron C, Balme B, Viallard AM, Barrut D, et al. Dermoscopic examination of nail pigmentation. Arch Dermatol. 2002;138(10):1327–33.PubMedGoogle Scholar
  11. 11.
    Thomas L, Dalle S. Dermoscopy provides useful information for the management of melanonychia striata. Dermatol Ther. 2007;20(1):3–10.PubMedGoogle Scholar
  12. 12.
    Tosti A, Argenziano G. Dermoscopy allows better management of nail pigmentation. Arch Dermatol. 2002;138(10):1369–70.PubMedGoogle Scholar
  13. 13.
    Dominguez-Cherit J, Roldan-Marin R, Pichardo-Velazquez P, Valente C, Fonte-Avalos V, Vega-Memije ME, et al. Melanonychia, melanocytic hyperplasia, and nail melanoma in a Hispanic population. J Am Acad Dermatol. 2008;59(5):785–91.PubMedGoogle Scholar
  14. 14.
    Leung AK, Robson WL, Liu EK, Kao CP, Fong JH, Leong AG, et al. Melanonychia striata in Chinese children and adults. Int J Dermatol. 2007;46(9):920–2.PubMedGoogle Scholar
  15. 15.
    Accordino RE, Langs-Barlow A, Phelps RG, Hammond B, Mercer SE. Transient, transverse melanonychia associated with Graves disease and acute hepatitis. Pediatr Dermatol. 2012;29(2):220–2.PubMedGoogle Scholar
  16. 16.
    Ajith C, Handa S. Laugier-Hunziker pigmentation. Indian J Dermatol Venereol Leprol. 2005;71(5):354–6.PubMedGoogle Scholar
  17. 17.
    Baran R. Longitudinal melanonychia in localized scleroderma. J Am Acad Dermatol. 2004;50(3):e11–e3.Google Scholar
  18. 18.
    de Carvalho VO, da Cruz CR, Marinoni LP, Lima JH. Transverse leukonychia and AIDS. Arch Dis Child. 2006;91(4):326.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Elmansour I, Chiheb S, Benchikhi H. Nail changes in connective tissue diseases: a study of 39 cases. Pan Afr Med J. 2014;18:150.PubMedPubMedCentralGoogle Scholar
  20. 20.
    Falodun O, Ogunbiyi A, Salako B, George AK. Skin changes in patients with chronic renal failure. Saudi J Kidney Dis Transpl. 2011;22(2):268–72.PubMedGoogle Scholar
  21. 21.
    Guarneri C, Bevelacqua V, Nunnari G. Nail pigmentation and fatigue. Cleve Clin J Med. 2012;79(11):785–6.PubMedGoogle Scholar
  22. 22.
    Kolla PK, Desai M, Pathapati RM, Mastan Valli B, Pentyala S, Madhusudhan Reddy G, et al. Cutaneous manifestations in patients with chronic kidney disease on maintenance hemodialysis. ISRN Dermatol. 2012;2012:679619.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Muallem MM, Rubeiz NG. Physiological and biological skin changes in pregnancy. Clin Dermatol. 2006;24(2):80–3.PubMedGoogle Scholar
  24. 24.
    Grover C, Kubba S, Bansal S, Nanda S, Reddy BS. Pigmentation: a potential cutaneous marker for AIDS? J Dermatol. 2004;31(9):756–60.PubMedGoogle Scholar
  25. 25.
    Murgic L, Grubisic F, Jajic Z. Unrecognized ochronosis – a case report. Acta Clin Croat. 2008;47(2):105–9.PubMedGoogle Scholar
  26. 26.
    Namakoola I, Wakeham K, Parkes-Ratanshi R, Levin J, Mugagga T, Seymour C, et al. Use of nail and oral pigmentation to determine ART eligibility among HIV-infected Ugandan adults. Tropical Med Int Health. 2010;15(2):259–62.Google Scholar
  27. 27.
    Pal P, Giri PP. Orange-brown chromonychia, a novel finding in Kawasaki disease. Rheumatol Int. 2013;33(5):1207–9.PubMedGoogle Scholar
  28. 28.
    Sendagorta E, Feito M, Ramirez P, Gonzalez-Beato M, Saida T, Pizarro A. Dermoscopic findings and histological correlation of the acral volar pigmented maculae in Laugier-Hunziker syndrome. J Dermatol. 2010;37(11):980–4.PubMedGoogle Scholar
  29. 29.
    Tessarotto L, Rubin G, Bonadies L, Valerio E, Cutrone M. Orange-brown chromonychia and Kawasaki disease: a possible novel association? Pediatr Dermatol. 2015;32(3):e104–5.PubMedGoogle Scholar
  30. 30.
    Wang WM, Wang X, Duan N, Jiang HL, Huang XF. Laugier-Hunziker syndrome: a report of three cases and literature review. Int J Oral Sci. 2012;4(4):226–30.PubMedPubMedCentralGoogle Scholar
  31. 31.
    Zaiac MN, Walker A. Nail abnormalities associated with systemic pathologies. Clin Dermatol. 2013;31(5):627–49.PubMedGoogle Scholar
  32. 32.
    Scarborough M, Gordon SB, French N, Phiri C, Musaya J, Zijlstra EE. Grey nails predict low CD4 cell count among untreated patients with HIV infection in Malawi. AIDS. 2006;20(10):1415–7.PubMedGoogle Scholar
  33. 33.
    Saito T, Uchi H, Moroi Y, Kiryu H, Furue M. Subungual Bowen disease revealed by longitudinal melanonychia. J Am Acad Dermatol. 2012;67(5):e240–1.PubMedGoogle Scholar
  34. 34.
    Fernandes Massa A, Debarbieux S, Depaepe L, Dalle S, Balme B, Thomas L. Pigmented squamous cell carcinoma of the nail bed presenting as a melanonychia striata: diagnosis by perioperative reflectance confocal microscopy. Br J Dermatol. 2013;169(1):198–9.PubMedGoogle Scholar
  35. 35.
    Ishida M, Iwai M, Yoshida K, Kagotani A, Okabe H. Subungual pigmented squamous cell carcinoma presenting as longitudinal melanonychia: a case report with review of the literature. Int J Clin Exp Pathol. 2014;7(2):844–7.PubMedPubMedCentralGoogle Scholar
  36. 36.
    de Berker DA, Wlodek C, Bristow IR. Subungual corn: a tender pigmented subungual lesion in older people. Br J Dermatol. 2014;171(1):69–72.PubMedGoogle Scholar
  37. 37.
    Kwok C, Merchant WJ, Hussain W. Superficial acral fibromyxoma presenting as a haemorrhagic pigmented streak on the toenail. Clin Exp Dermatol. 2013;38(5):553–4.PubMedGoogle Scholar
  38. 38.
    Ferreira O, Baudrier T, Mota A, Tellechea O, Cruz MJ, Guimaraes M, et al. Onycotrychia?: subungual hair follicle as another cause of longitudinal melanonychia or pigmentation – hair follicle as cause of melanonychia. J Eur Acad Dermatol Venereol. 2010;24(10):1238–40.PubMedGoogle Scholar
  39. 39.
    Inamadar AC, Palit A. Nail photography: all 10 fingernails in 1 frame. J Am Acad Dermatol. 2015;73(4):e143.PubMedGoogle Scholar
  40. 40.
    Angel TA, Stalkup JR, Hsu S. Photodistributed blue-gray pigmentation of the skin associated with long-term imipramine use. Int J Dermatol. 2002;41(6):327–9.PubMedGoogle Scholar
  41. 41.
    Aste N, Fumo G, Contu F, Aste N, Biggio P. Nail pigmentation caused by hydroxyurea: report of 9 cases. J Am Acad Dermatol. 2002;47(1):146–7.PubMedGoogle Scholar
  42. 42.
    Balagula Y, Lacouture ME, Cotliar JA. Dermatologic toxicities of targeted anticancer therapies. J Support Oncol. 2010;8(4):149–61.PubMedGoogle Scholar
  43. 43.
    Baykal Y, Baykal C, Ozer S, Tulunay G. Topotecan induced nail pigmentation. J Dermatol. 2004;31(11):951–2.PubMedGoogle Scholar
  44. 44.
    Chawre SM, Pore SM, Nandeshwar MB, Masood NM. Zidovudine-induced nail pigmentation in a 12-year-old boy. Indian J Pharmacol. 2012;44(6):801–2.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Chew L, Chuen VS. Cutaneous reaction associated with weekly docetaxel administration. J Oncol Pharm Pract. 2009;15(1):29–34.PubMedGoogle Scholar
  46. 46.
    Clerico R, Corsetti P, Ambrifi M, Paolino G, Rossi MR, Bottoni U, et al. Longitudinal melanonychia in a patient with essential thrombocytosis under treatment with hydroxyurea. Acta Dermatovenerol Croat. 2012;20(4):281–3.PubMedGoogle Scholar
  47. 47.
    Ceulen RP, Frank J, Poblete-Gutierrez P. Nail pigmentation due to hydroxycarbamide. Int J Dermatol. 2007;46(Suppl 3):13–5.PubMedGoogle Scholar
  48. 48.
    Dasanu CA, Vaillant JG, Alexandrescu DT. Distinct patterns of chromonychia, Beau’s lines, and melanoderma seen with vincristine, adriamycin, dexamethasone therapy for multiple myeloma. Dermatol Online J. 2006;12(6):10.PubMedGoogle Scholar
  49. 49.
    Dave S, Thappa DM. Peculiar pattern of nail pigmentation following cyclophosphamide therapy. Dermatol Online J. 2003;9(3):14.PubMedGoogle Scholar
  50. 50.
    Jeevankumar B, Thappa DM. Blue lunula due to hydroxyurea. J Dermatol. 2003;30(8):628–30.PubMedGoogle Scholar
  51. 51.
    Joyner S, Lee D, Hay P, Lau R. Hydroxyurea-induced nail pigmentation in HIV patients. HIV Med. 1999;1(1):40–2.PubMedGoogle Scholar
  52. 52.
    Kumar S, Dixit R, Karmakar S, Paul S. Unusual nail pigmentation following cyclophosphamide-containing chemotherapy regimen. Indian J Pharmacol. 2010;42(4):243–4.PubMedPubMedCentralGoogle Scholar
  53. 53.
    Kumar B, Saraswat A, Kaur I. Mucocutaneous adverse effects of hydroxyurea: a prospective study of 30 psoriasis patients. Clin Exp Dermatol. 2002;27(1):8–13.PubMedGoogle Scholar
  54. 54.
    Lencastre A, Lobo M, Joao A. Argyria – case report. An Bras Dermatol. 2013;88(3):413–6.PubMedPubMedCentralGoogle Scholar
  55. 55.
    Lopes M, Jordao C, Grynszpan R, Sodre C, Ramos ESM. Chromonychia secondary to chemotherapy. Case Rep Dermatol. 2013;5(2):163–7.PubMedPubMedCentralGoogle Scholar
  56. 56.
    Ban M, Kitajima Y. Nail discoloration occurring after 8 weeks of minocycline therapy. J Dermatol. 2007;34(10):699–701.PubMedGoogle Scholar
  57. 57.
    Minisini AM. Taxane-induced nail changes: incidence, clinical presentation and outcome. Ann Oncol. 2003;14(2):333–7.PubMedGoogle Scholar
  58. 58.
    Paravar T, Hymes SR. Longitudinal melanonychia induced by capecitabine. Dermatol Online J. 2009;15(10):11.PubMedGoogle Scholar
  59. 59.
    Patel GK, Logan RA. Golden nail pigmentation. J Dermatolog Treat. 2002;13(1):41–2.PubMedGoogle Scholar
  60. 60.
    Piraccini BM, Iorizzo M, Antonucci A, Tosti A. Drug-induced nail abnormalities. Expert Opin Drug Saf. 2004;3(1):57–65.PubMedGoogle Scholar
  61. 61.
    Ranawaka RR. Patterns of chromonychia during chemotherapy in patients with skin type V and outcome after 1 year of follow-up. Clin Exp Dermatol. 2009;34(8):e920–6.PubMedGoogle Scholar
  62. 62.
    Randi ML, Ruzzon E, Tezza F, Luzzatto G, Fabris F. Toxicity and side effects of hydroxyurea used for primary thrombocythemia. Platelets. 2005;16(3–4):181–4.PubMedGoogle Scholar
  63. 63.
    Saluja SS, Bowen AR, Hull CM. Resident rounds: part III – case report: argyria – a case of blue-gray skin. J Drugs Dermatol. 2015;14(7):760–1.PubMedGoogle Scholar
  64. 64.
    Serrano-Falcon C, Pugnaire MA, Serrano-Falcon Mdel M, Morales MG, Serrano-Ortega S. Toxicoderma caused by hydroxyurea. Int J Dermatol. 2011;50(11):1435–7.PubMedGoogle Scholar
  65. 65.
    Garin Shkolnik T, Feuerman H, Didkovsky E, Kaplan I, Bergman R, Pavlovsky L, et al. Blue-gray mucocutaneous discoloration: a new adverse effect of ezogabine. JAMA Dermatol. 2014;150(9):984–9.PubMedGoogle Scholar
  66. 66.
    Srikant M, Van Veen J, Raithatha A, Reilly JT. Cyclophosphamide-induced nail pigmentation. Br J Haematol. 2002;117(1):2.PubMedGoogle Scholar
  67. 67.
    Takci Z, Ozoguz P. Nail discoloration due to tinzaparin sodium. Cutan Ocul Toxicol. 2012;31(4):332–4.PubMedGoogle Scholar
  68. 68.
    Teo RY, Tan E. A case of hydroxyurea-induced transverse melanonychia. Int J Dermatol. 2006;45(11):1329–30.PubMedGoogle Scholar
  69. 69.
    Tsilika K, Tran A, Trucchi R, Pop S, Anty R, Cardot-Leccia N, et al. Secondary hyperpigmentation during interferon alfa treatment for chronic hepatitis C virus infection. JAMA Dermatol. 2013;149(6):675–7.PubMedGoogle Scholar
  70. 70.
    Zargari O, Kimyai-Asadi A, Jafroodi M. Cutaneous adverse reactions to hydroxyurea in patients with intermediate thalassemia. Pediatr Dermatol. 2004;21(6):633–5.PubMedGoogle Scholar
  71. 71.
    Baumert BG, Wodarski C, Klein C, Wendt T. Transverse melanonychia (TM): induced by radiotherapy. Radiother Oncol. 2015;114(2):282–3.PubMedGoogle Scholar
  72. 72.
    Kaptanoglu AF, Oskay T. Symmetrical melanonychia of the thumbnails associated with PUVA in psoriasis. J Dermatol. 2004;31(2):148–50.PubMedGoogle Scholar
  73. 73.
    Garcia-Garcia SC, Barbosa-Moreno LE, Martinez-Cabriales SA, Gonzalez-Ramirez RA, Ocampo-Candiani J. Exogenous nail pigmentation secondary to pecan nuts (Carya illinoinensis). J Am Acad Dermatol. 2015;73(4):e139–40.PubMedGoogle Scholar
  74. 74.
    Gregoriou S, Kazakos C, Rigopoulos D. Yellow chromonychia after ascorbic acid application. Clin Exp Dermatol. 2011;36(6):671–2.PubMedGoogle Scholar
  75. 75.
    Harada K, Morohoshi T, Ikeda T, Shimada S. A patient with pseudochromhidrosis presenting with pink nails. J Am Acad Dermatol. 2012;67(2):e74–5.PubMedGoogle Scholar
  76. 76.
    Adigun CG, Scher RK. Longitudinal melanonychia: when to biopsy and is dermoscopy helpful? Dermatol Ther. 2012;25(6):491–7.PubMedGoogle Scholar
  77. 77.
    Jellinek N. Nail matrix biopsy of longitudinal melanonychia: diagnostic algorithm including the matrix shave biopsy. J Am Acad Dermatol. 2007;56(5):803–10.PubMedGoogle Scholar
  78. 78.
    Piraccini BM, Dika E, Fanti PA. Tips for diagnosis and treatment of nail pigmentation with practical algorithm. Dermatol Clin. 2015;33(2):185–95.PubMedGoogle Scholar
  79. 79.
    Sawada M, Yokota K, Matsumoto T, Shibata S, Yasue S, Sakakibara A, et al. Proposed classification of longitudinal melanonychia based on clinical and dermoscopic criteria. Int J Dermatol. 2014;53(5):581–5.PubMedGoogle Scholar
  80. 80.
    Haneke E, Baran R. Longitudinal melanonychia. Dermatol Surg. 2001;27(6):580–4.PubMedGoogle Scholar
  81. 81.
    Theunis A, Richert B, Sass U, Lateur N, Sales F, Andre J. Immunohistochemical study of 40 cases of longitudinal melanonychia. Am J Dermatopathol. 2011;33(1):27–34.PubMedGoogle Scholar
  82. 82.
    Richert B, Theunis A, Norrenberg S, Andre J. Tangential excision of pigmented nail matrix lesions responsible for longitudinal melanonychia: evaluation of the technique on a series of 30 patients. J Am Acad Dermatol. 2013;69(1):96–104.PubMedGoogle Scholar
  83. 83.
    Levit E, Kagen M, Scher R, Grossman M, Altman E. The ABC rule for clinical detection of subungual melanoma☆, ☆☆. J Am Acad Dermatol. 2000;42(2):269–74.PubMedGoogle Scholar
  84. 84.
    Finch J, Arenas R, Baran R. Fungal melanonychia. J Am Acad Dermatol. 2012;66(5):830–41.PubMedGoogle Scholar
  85. 85.
    Kilinc Karaarslan I, Acar A, Aytimur D, Akalin T, Ozdemir F. Dermoscopic features in fungal melanonychia. Clin Exp Dermatol. 2015;40(3):271–8.PubMedGoogle Scholar
  86. 86.
    Cooper C, Arva NC, Lee C, Yelamos O, Obregon R, Sholl LM, et al. A clinical, histopathologic, and outcome study of melanonychia striata in childhood. J Am Acad Dermatol. 2015;72(5):773–9.PubMedGoogle Scholar
  87. 87.
    Sawada M, Ishizaki S, Kobayashi K, Dekio I, Tanaka M. Longterm digital monitoring in the diagnosis and management of congenital nevi of the nail apparatus showing pseudo-Hutchinson’s sign. Dermatol Pract Concept. 2014;4(2):37–40.PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Dermatology and Dermatopathology, UWSMPHMadisonUSA

Personalised recommendations