Warning Signs Of Alm Include:
- a new streak in a nail that is not caused by an accident or bruise
- a nail streak that has damaged the fingernail
- a changing spot in or connected to a mole on the foot or hand
- an irregularly-shaped growth on the foot or hand that is changing, growing or has an unusual color
- an elevated, thickened patch growing on the sole of the foot or palm of the hand
Two Big Warning Signs Of Nail Melanoma
Hutchinsons sign. The Hutchinsons sign is when the pigment in the nail extends to the nail fold , says Dr. Ilyas. This sign is considered ominous for a melanoma of the nail.
Hutchinsons sign. The pigment is leaking into the skin near the cuticle.
Whats even scarier is that a benign pigment in the nail bed can create a pseudo-Hutchinsons sign.
To a layperson, this appears to be a true Hutchinsons sign. But a dermatologist knows what to look for that would indicate a benign finding.
Nevertheless, if you see what seems to be the Hutchinsons sign get to a dermatologist.
Progression and evolution. Dr. Ilyas explains, Pigment or color that extends or spreads over time is concerning for a melanoma.
The obvious progression in this case is the destruction of the top corner of the nail which is right above an obvious Hutchinsons sign. Ann Dermatol. 2018 Feb 30
It is not uncommon for people to present with a benign pigmented streak of the nail.
These tend to have clear defined edges, not extend to the nail fold, and stay stable, says Dr. Ilyas.
If the color of this streak starts to become hazy along the edges or darker over time, this can be suspicious for a cancer and should be evaluated.
Subungual Melanoma: Exact Location of Tumor
The tumor is not literally IN the nail that part of the finger or toe that you trim or paint.
The cancer is actually underneath the nail, in the matrix, and it shows through the nail.
Differences In Appearance Between Blood Under A Toenail And A Melanoma: Under More Scrutiny
Association with trauma. The trauma that leads to blood under a toenail isnt always blunt and painful at the time of occurrence.
It could be as seemingly innocuous as jogging downhill in footwear that isnt roomy enough. The patient might not even recall the trauma.
Though subungual hematoma often affects both big toes at the same time, it CAN occur in only one toe.
If your right foot is a little bigger than the left, the shoe on your right foot will have a tighter fit that may result in a hematoma, while the shoe on the left wont.
More than one toenail. If the appearance of the dark pigment in a big toe coincides with a similar-looking pigment in another toe either on that foot or the other then this points to a benign cause.
Blood grows out. If you view a hematoma every several days, youll notice that the space between the portion closest to the cuticle and the cuticle is getting bigger, or showing more nail.
As the nail is pushed out, the blood underneath goes with it. So if you noticed the pigment when it was first visibly connected to the cuticle area, in a few weeks it will be closer to the center of the nail, then after several more weeks itll be near the top of the nail. It can take several months to finally grow out.
Eventually the nail will be long enough such that when you trim it, youll also be trimming out the old dried blood.
A melanoma will stay firmly adhered to its place it will not move upward as the nail grows.
What Causes Subungual Melanoma
Subungual melanoma is more common in Native American, African American, and Asian individuals. It usually has a brown-black pigment, and a blurred border. When melanoma changes, it means size increase and / or growth speed of the nail or the pigment. When there is no apparent change, we speak of nail dystrophy, which person does not improve despite an adequate treatment. Subungual melanoma extension affects to the pigmentation to the proximal or lateral nail fold , or to the free edge of the nail. The family clinical history of melanoma , as well as dysplastic nevus syndrome, are determining factors in the appearance of the subungual melanoma, since the probability of developing this cancer increases significantly. Professional medical research does not consider the development of this cancer due to prolonged exposure to the sun.
Medical and health professionals have found evidence linking subungual melanoma and trauma. 58% of subungual melanoma of the hand is located in the thumb, and 86% of the subungual melanoma of the foot is located in the first finger, probably because of the larger size of the nail bed , also because they are the more exposed to trauma fingers. The morphology can be very variable, from a longitudinal brown band , to a destruction of the nail articulation, or macular lesions in the nail bed extending from the matrix. Up to 20% of subungual melanoma are amelanotic, making diagnosis especially difficult.
Blood Beneath The Nail
This is what we call a subungual haematoma which translates to blood beneath the nail. There are many reasons why you may get bleeding beneath the nail, and before you worry, most of these are harmless and comparable to getting bruising beneath your skin.
Examples include impact injury, like having your toe stood on in sports or dropping something heavy on your foot, stubbing your toe, wearing tight shoes that press on your toes, keeping your nails too long so that theyre constantly buttressing against the end of the shoe, and the like.
Depending on the size of the bleeding and the spot, you may lose your toenail. If this happens, its likely that the nail will simply grow back with little harm done, though as toenails grow slowly, it may take anywhere from 9-18 months.
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Concerned About What Youre Seeing
Nail problems should never have you worried or keep you awake at night and if they are, we highly recommend trusting those instincts and having your nails checked. Our podiatry team will give you an idea of what the likely cause for your nail discolouration is and treat it accordingly or refer you to a specialist if we suspect something more sinister or further investigation is required.
How Are They Diagnosed
Initially, the doctor may use the ACBDEF method to help identify if the marks you have are cancerous.
Each letter represents a feature to consider as part of the diagnosis:
- A The age of the patient is taken into consideration because if you are over 50, the risk of getting this is higher.
- B Are there any bands and what color are they: Black or brown and are the borders of the bands blurred?
- C Has the mark changed at all since it was noticed? Getting bigger or darker can be a symptom.
- D Which digit is the mark affecting? It is mainly your big toe that is affected.
- E Has the coloration made any extension to the surrounding area?
- F Have your family had any history of cancer or specifically this type?
If anything is suspected, a proper diagnosis is done by taking a small biopsy of the tissue from under the nail.
This is done by punching or drilling through the nail and taking a sample from an affected area. It is done under local anaesthetic and does not take long to perform.
The sample is then examined by a Dermatopathologist who will be able to make an informed diagnosis.
This is not something you can diagnose yourself, so please see a doctor as soon as possible if you think you may have this problem.
Getting early medical advice or intervention is very important. You might think that it is just a brown spot under your toenail, but it does mean that you need to seek some help.
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Prevention And Early Detection
The exact cause of subungual melanoma is unknown, meaning that patients cannot take specific steps to prevent this condition. However, because it may be associated with trauma to the hands and feet, you may want to keep yours hands and feet protected.2 For example, you can protect your hands and feet by wearing gloves during heavy labor, or wearing protective gear and sturdy shoes during sports.
Early detection is crucial to the treatment of subungual melanoma, so be sure to tell your doctor about any changes to your nails.1 You can regularly check your nails, fingers, and toes for any bruising, streaking, or changes.3
Acral Lentiginous Melanoma Nail
- The frequently used ABCDE rule is not always helpful in nail acral lentiginous melanoma. This is because of the anatomy and continuous outgrowth in of the nail plate.
Picture 3 : Nail acral lentiginous melanoma
Image source : ncbi.nlm.nih.gov
This nail lesion can be seen from the distal third of the nail bed noting that it caused nail detachment.
Please see : ABCDE rule of malignant melanoma
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When To See A Foot Specialist
Lesions that occur on the nail unit or the soles of the feet need to be watched carefully for malignant transformation .
The bottom line – if you have a pigmented streak or spot, on your toenail, underneath your toenail or on the nail fold beside your toenail, no matter what the color, you should have it evaluated by a specialist. Little spots on little toenails could be signs of a big problem.
Yes Melanoma Can Affect A Fingernail Or Toenail And There Are Two Major Warning Signs That What You See Is A Potentially Deadly Tumor Also Known As Subungual Melanoma
Myths About Nail Melanoma
White people cant get it. Wrong, whites can get this disease, though its much more common in blacks and Asians.
Children cant get it. Wrong. There are cases of pediatric subungual melanoma.
Since it affects only the nail, its not that serious. Wrong. Like any other kind of melanoma, a tumor that affects the nail can penetrate and spread to other parts of the body via the lymphatic system.
Once this disease has spread to distant sites, prognosis is very poor.
Between one and two percent of all melanomas are the subungual type.
I routinely see patients in for streaks or dark spots in the nails, says Erum Ilyas, MD, a board certified dermatologist who performs adult and pediatric medical dermatology, cosmetic dermatology and skin cancer treatment with Schweiger Dermatology Group.
It goes without saying that if you google this one, you will undoubtedly see that this needs to be evaluated to rule out melanoma, says Dr. Ilyas.
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The 5 Stages Of Nail Melanoma
Nail melanoma is a life-threatening skin cancer that grows to affect the nails, usually the big toe and thumb. This disease can prove to be very deadly, however treatments are readily available if diagnosed early.
This disease is often referred to as, Malignant Melanoma of Nail Unit or Nail Unit Melanoma.
- The pigment producing cells of the body, called Melanocytes, is where the Melanoma cancer develops. The Melanocytes are responsible for giving our skin its color.
- The development of Melanoma cancer, usually begins from a finger or toenail, however thats not always the case.
- It has the tendency to affect the areas around such as the sides of nail or the nail bed. In fact, it may also spread to other parts of the body, if not treated on time.
- The big toe or thumb is usually the first to get affected, however it may vary according to each case.
- The Nail Unit Melanoma is divided into 3 main types:
- Nail Melanoma is most common in light/fair skinned people as opposed to dark skinned people.
There are 5 stages of Nail Melanoma, stated as follows
Stage 1: aka Stage O Melanoma
This stage is also referred to as Melanoma in situ, meaning site of origination of Melanoma. At this point, a tumor has formed on the outermost layer of the skin, epidermis.
Stage 2: aka Stage I Melanoma
This stage is further categorized into two:
Stage IA: At this stage, the tumor is less than a mm deep and has no signs of an ulcer.
Stage 3: aka Stage II Melanoma
Is It Toenail Fungus Or Something Else
Odd-looking toenail? It may be a fungal infection, but there’s a good chance that another condition could be to blame.
If you notice an odd spot on your toenail, you might assume its a fungal infection. However, theres a good chance that its not.
Spots or discolorations on or under a toenail could be bruises resulting from trauma to the nail, blood blisters, warts, or even subungual melanoma, a type of skin cancer, says Ami Sheth, a doctor of podiatric medicine in Los Gatos, California, and a spokesperson for the American Podiatric Medical Association.
Since nail irregularities can be caused by diseases besides these as well, its best to get it looked at, says Dr. Sheth.
Richard Goad, a doctor of podiatric medicine at Baylor Scott & White Health in Waco, Texas, concurs. Sometimes the nail will be the first place to show another underlying problem, Dr. Goad says.
So is it a fungus, a false alarm, or another condition entirely?
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How Fast Does Subungual Melanoma Grow
Subungual melanoma often begins as a visible pigment band on the length of the nail plate . For weeks or months, the pigment band:
- Grows, especially in the proximal termination .
- Becomes more irregular in pigmentation, including light brown and dark brown.
- Extends by becoming involved in the adjacent nail fold .
- Can develop a lump, ulcerate or bleed.
- Can lead to thinning, cracks or deformation of the nail plate .
However, up to half of all cases of subungual melanoma are amelanotic . Nail melanoma may form a lump under the surface of the nail, lifting it . Sometimes it may look like a verrucous wart. It is usually painless, but the advanced tumor invades the underlying bone, which can origin a grim pain.
Other Things To Know About Acral Lentiginous Melanoma
As an ALM tumor increases in size, it usually becomes more irregular in shape and color .
The surface of the ALM lesion may remain flat, even as the tumor invades deeply into the skin.
Thickening ALM on the sole of the foot can make walking painful and be mistaken for a plantar wart.
The surface of a spot of ALM may also start out smooth and become bumpier or rougher as it evolves. If a tumor begins to grow from the cancerous skin cells, the skin will become more bulbous, discolored, and rough to the touch.
Less advanced cancers and thinner tumors have better survival rates. Raised tumors tend to be more aggressive.
Men are more likely than women to have thick, large tumors at diagnosis.
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Acral Lentiginous Melanoma Causes
- Some studies have suggested that trauma to the foot can be a cause. This is because the most common place for the tumor is on the heal or ball of the feet. These areas receive the most impact during walking or running.
- Prolonged sun exposure
Picture 1 : Prolonged sun exposure
Image source : medscape.com
Growth phases are known as:
- Preliminary radial growth of atypical lentiginous cells at dermal-epidermal interface.
- Expansible growth into the papillary dermis or infiltrative vertical growth in the reticula dermis.
- Cytology of themalignant cell
- Response of the epidermis to the melanocytes
- Immune response.
Prognosis And Survival Rate
- ALM can look a lot like lentigo maligna melanoma but has been noted to be more aggressive and have a worse prognosis.
- Prognosis is much better the sooner it is diagnosed.
- Prognosis is directly related to the size and depth of the tumor or lesion.
- Often times the delay in diagnosis is because clinically it can appear to be benign.
Please note : Famous musician Bob Marley died of this cancer
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What Is The Outlook For Patients With Melanoma Affecting The Nail Unit
The main factor associated with the risk of spread of melanoma and death is the thickness of the melanoma at the time of complete excision of the primary tumour. Delay in diagnosis is common with subungual melanoma, particularly when it affects the toe, and some of these tumours have already spread at the time of diagnosis.
The 5-year survival rate ranges widely from 16% to 87%, depending on the series, with two larger series in the 51% to 55% range .
Look For The Signs Of Melanoma
When this skin cancer develops on a foot, you may see the ABCDEs of melanoma, but its also possible for a melanoma to have different features. Aside from looking like a changing mole, a melanoma on the foot can appear as a:
Brown or black vertical line under a toenail
Pinkish-red spot or growth
New spot or growth where you injured your foot
Rapidly growing mass on your foot, especially where you once injured your foot
Non-healing sore on your foot
Sore that looks like a diabetic ulcer
Sometimes, melanoma on the foot feels painful, bleeds, or itches, but not always. The bleeding tends to stop and start.
The following pictures show you what melanoma can look like on the foot.
Melanoma on the bottom of a toe
You can see some of the ABCDEs of melanoma. One half of this spot is unlike the other, it has an uneven border, and the color varies within the spot.
Melanoma on the bottom of a foot
Here, you can also see some of ABCDEs of melanoma, such as one half is unlike the other and it is larger than the eraser on a pencil.
Melanoma on the bottom of the foot
In this picture, you can see some of the ABCDEs of melanoma, such as more than one color, uneven border, and one half is unlike the other.
Melanoma beneath a toenail
On the feet and hands, melanoma can begin as a dark vertical line underneath a nail.
Melanoma on a callused heel
You may see melanoma that is brown, black, reddish pink, or flesh colored, and it can appear in just about any shape.
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