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Two kinds of Hutchinson's sign, benign and malignant
Brief reports 305
J AM ACAD DERMATOL VOLUME 44, NUMBER 2
Two kinds of Hutchinson’s sign, benign and malignant Yasuhiro Kawabata, MD,a Kuniaki Ohara, MD,b Haruko Hino, MD,c and Kunihiko Tamaki, MDa Tokyo, Japan We examined 6 subungual melanomas in situ and 18 melanocytic nevi and compared pigmentation of the nail plates and hyponychium with the use of a dermatoscope. Hutchinson’s sign on the hyponychium was not always evidence of subungual melanoma because it can be seen in both diseases. However, there was a wide difference in their dermatoscopic features. We believe that observation of pigmentation on the hyponychium with the use of a dermatoscope contributes to the precise diagnosis of subungual melanoma. (J Am Acad Dermatol 2001;44:305-7.)
T
he incidence of and the predilection for malignant melanoma vary among populations. Malignant melanoma with acral lesions (acral lentiginous melanoma) is more common in Asian persons than in white people, including subungual areas.1 Subungual melanoma (malignant melanoma of the nail apparatus) appears initially as melanonychia striata longitudinalis in the nail plate. It is often difficult to differentiate the early stage of subungual melanoma from melanocytic nevus of the nail apparatus because neither condition is associated with nail deformities such as ulceration, destruction, or thickening.2 However, correct diagnosis of early melanoma is very important because the prognosis and the treatment are quite different from those of melanocytic nevus. Saida and Ohshina3 delineated the clinical characteristics of early subungual melanoma, especially melanoma in situ. In their report, they suggested Hutchinson’s sign, which is periungual pigmentation accompanied by melanonychia, as the most significant sign in the differentiation between subungual melanoma and melanocytic nevus. However, pigmentation on the hyponychium sometimes can be seen in benign melanocytic nevus.
From the Department of Dermatology, Faculty of Medicine, University of Tokyo,a the Department of Dermatology, Toranomon Hospital,b and the Department of Dermatology, Kantochuo Hospital.c Reprint requests: Yasuhiro Kawabata, Department of Dermatology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo, 1138655 Japan. E-mail: [email protected]. Copyright © 2001 by the American Academy of Dermatology, Inc. 0190-9622/2001/$35.00 + 0 16/54/112398 doi:10.1067/mjd.2001.112398
A
B
C
D
E
F
Fig 1. Subungual melanomas in situ of the left third finger in 57-year-old man (A-D) and of the left first finger in 72-year-old man (E and F). A, Clinical finding of the nail plate. B, Clinical finding of the fingertip (Hutchinson’s sign). C, Dermatoscopic view of the nail plate; longitudinal pigmented streaks in the entire nail plate. D, Dermatoscopic view of the fingertip; haphazard pigmentation distributed in a disorderly fashion. E, Dermatoscopic view of the nail plate. F, Dermatoscopic view of the fingertip.
PATIENTS AND METHODS In the current study, 6 subungual melanomas in situ (patient ages, 49-89 years) and 18 melanocytic nevi (patient ages, 2-38 years) were examined. We compared pigmentation of the nail plates and hyponychium of benign melanocytic nevi with those of malig-
306 Brief reports
J AM ACAD DERMATOL FEBRUARY 2001
B A Fig 2. Melanocytic nevi of the right second fingernail in 2-year-old boy (A) and the left first fingernail in another 2-year-old boy (B): Dermatoscopic views. Brushy linear pigmentation across the skin marks.
nant melanoma by means of a dermatoscope, which is a type of epiluminescence microscope. All cases clinically diagnosed as malignant melanomas were confirmed as melanomas by histologic examination. Eleven cases with benign melanocytic nevi, in which the breadth of melanonychia was less than half of the nail plate and remained unchanged more than 3 years after the first visit, were clinically diagnosed as benign melanocytic nevi. Six cases, in which breadth of melanonychia was more than half of the nail plate, were histopathologically confirmed to be benign melanocytic nevi. We diagnosed and observed one case (patient was 6 years old) as a benign melanocytic nevus; the entire nail plate was involved and the shade of pigmentation has been getting light gradually.
nevus, although dermatoscopic features of the nail plates are indistinguishable (Fig 1, C and E; Fig 2). The pattern of pigmentation of melanocytic nevus had a brushy linear structure across the skin marks (Fig 2). It was similar to the dermatoscopic features of acquired plantar melanocytic nevus (linear pigmentation in the furrows or across the skin marks is suggestive of a benign nevus).4-6 In contrast, subungual melanoma in situ exhibited haphazard pigmentation distributed in a disorderly fashion over the entire surface (Fig 1, D and F). It was similar to those of acral lentiginous melanoma in situ, as we had previously reported (irregular pigmentation on the ridges or over the entire surface is suggestive of melanoma).6
DISCUSSION RESULTS In all 6 cases of melanoma, the initial sign was longitudinal pigmented streaks in the nail plate, which increased in breadth to finally involve the entire nail plate without deformities (Fig 1, A). Hutchinson’s sign (periungual pigmentation) was also observed in all 6 cases (Fig 1, B). In melanocytic nevus, 15 cases showed partial pigmentation in the nail plates. In 3 cases, the entire nail plate was involved without any deformities. Pigmented macules of the fingertip were seen in the same 3 cases (Fig 2) and in another 2 cases. It is noteworthy that hyponychial pigmentation, which has been generally regarded as a sign of subungual melanoma, is observed in melanocytic nevus. However, the surface profiles of the hyponychial pigmentation of subungual melanomas obtained by the dermatoscope were different from those of melanocytic
Hutchinson’s sign, especially on the hyponychium, is not always evidence of subungual melanoma because it can be seen in both melanoma and melanocytic nevus. However, there is a wide difference in dermatoscopic features between the two. We considered that the dermatoscopic features that distinguish subungual melanoma from melanocytic nevus are linear brushy pattern indicating the benign condition and the diffuse haphazard pattern indicating the malignant condition. We believe that observation of pigmentation on the hyponychium by means of a dermatoscope contributes to the precise differential diagnosis of melanonychia striata with Hutchinson’s sign. REFERENCES 1. Kukita A, Ishihara K. Clinical features and distribution of malignant melanoma and pigmented nevi on the soles of the feet in Japan. J Invest Dermatol 1989;92(Suppl 5):210S-3S.
J AM ACAD DERMATOL VOLUME 44, NUMBER 2
2. Kato T, Usuba Y, Takemasu H, Tagami H. Rapidly growing nail streak resulting in diffuse melanosis of the nail: a possible sign of subungual melanoma in situ. Cancer 1989;64:2191-7. 3. Saida T, Ohshina Y. Clinical and histopathologic characteristics of early lesions of subungual malignant melanoma. Cancer 1989;63:556-60. 4. Akasu R, Sugiyama H, Araki M, Ohtake N, Furue M, Tamaki K. Dermatoscopic and videomicroscopic features of melanocytic plantar nevi. Am J Dermatopathol 1996;18:10-8.
Brief reports 307
5. Oguchi S, Saida T, Koganehira Y, Ohkubo S, Ishihara Y, Kawachi S. Characteristic epiluminescent microscopic features of early malignant melanoma on glabrous skin. Arch Dermatol 1998; 134:563-8. 6. Kawabata Y, Tamaki K. Distinctive dermatoscopic features of acral lentiginous melanoma in situ from plantar melanocytic nevi and their histopathologic correlation. J Cutan Med Surg 1998;2:199-204.
J AM ACAD DERMATOL VOLUME 44, NUMBER 2
Two kinds of Hutchinson’s sign, benign and malignant Yasuhiro Kawabata, MD,a Kuniaki Ohara, MD,b Haruko Hino, MD,c and Kunihiko Tamaki, MDa Tokyo, Japan We examined 6 subungual melanomas in situ and 18 melanocytic nevi and compared pigmentation of the nail plates and hyponychium with the use of a dermatoscope. Hutchinson’s sign on the hyponychium was not always evidence of subungual melanoma because it can be seen in both diseases. However, there was a wide difference in their dermatoscopic features. We believe that observation of pigmentation on the hyponychium with the use of a dermatoscope contributes to the precise diagnosis of subungual melanoma. (J Am Acad Dermatol 2001;44:305-7.)
T
he incidence of and the predilection for malignant melanoma vary among populations. Malignant melanoma with acral lesions (acral lentiginous melanoma) is more common in Asian persons than in white people, including subungual areas.1 Subungual melanoma (malignant melanoma of the nail apparatus) appears initially as melanonychia striata longitudinalis in the nail plate. It is often difficult to differentiate the early stage of subungual melanoma from melanocytic nevus of the nail apparatus because neither condition is associated with nail deformities such as ulceration, destruction, or thickening.2 However, correct diagnosis of early melanoma is very important because the prognosis and the treatment are quite different from those of melanocytic nevus. Saida and Ohshina3 delineated the clinical characteristics of early subungual melanoma, especially melanoma in situ. In their report, they suggested Hutchinson’s sign, which is periungual pigmentation accompanied by melanonychia, as the most significant sign in the differentiation between subungual melanoma and melanocytic nevus. However, pigmentation on the hyponychium sometimes can be seen in benign melanocytic nevus.
From the Department of Dermatology, Faculty of Medicine, University of Tokyo,a the Department of Dermatology, Toranomon Hospital,b and the Department of Dermatology, Kantochuo Hospital.c Reprint requests: Yasuhiro Kawabata, Department of Dermatology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo, 1138655 Japan. E-mail: [email protected]. Copyright © 2001 by the American Academy of Dermatology, Inc. 0190-9622/2001/$35.00 + 0 16/54/112398 doi:10.1067/mjd.2001.112398
A
B
C
D
E
F
Fig 1. Subungual melanomas in situ of the left third finger in 57-year-old man (A-D) and of the left first finger in 72-year-old man (E and F). A, Clinical finding of the nail plate. B, Clinical finding of the fingertip (Hutchinson’s sign). C, Dermatoscopic view of the nail plate; longitudinal pigmented streaks in the entire nail plate. D, Dermatoscopic view of the fingertip; haphazard pigmentation distributed in a disorderly fashion. E, Dermatoscopic view of the nail plate. F, Dermatoscopic view of the fingertip.
PATIENTS AND METHODS In the current study, 6 subungual melanomas in situ (patient ages, 49-89 years) and 18 melanocytic nevi (patient ages, 2-38 years) were examined. We compared pigmentation of the nail plates and hyponychium of benign melanocytic nevi with those of malig-
306 Brief reports
J AM ACAD DERMATOL FEBRUARY 2001
B A Fig 2. Melanocytic nevi of the right second fingernail in 2-year-old boy (A) and the left first fingernail in another 2-year-old boy (B): Dermatoscopic views. Brushy linear pigmentation across the skin marks.
nant melanoma by means of a dermatoscope, which is a type of epiluminescence microscope. All cases clinically diagnosed as malignant melanomas were confirmed as melanomas by histologic examination. Eleven cases with benign melanocytic nevi, in which the breadth of melanonychia was less than half of the nail plate and remained unchanged more than 3 years after the first visit, were clinically diagnosed as benign melanocytic nevi. Six cases, in which breadth of melanonychia was more than half of the nail plate, were histopathologically confirmed to be benign melanocytic nevi. We diagnosed and observed one case (patient was 6 years old) as a benign melanocytic nevus; the entire nail plate was involved and the shade of pigmentation has been getting light gradually.
nevus, although dermatoscopic features of the nail plates are indistinguishable (Fig 1, C and E; Fig 2). The pattern of pigmentation of melanocytic nevus had a brushy linear structure across the skin marks (Fig 2). It was similar to the dermatoscopic features of acquired plantar melanocytic nevus (linear pigmentation in the furrows or across the skin marks is suggestive of a benign nevus).4-6 In contrast, subungual melanoma in situ exhibited haphazard pigmentation distributed in a disorderly fashion over the entire surface (Fig 1, D and F). It was similar to those of acral lentiginous melanoma in situ, as we had previously reported (irregular pigmentation on the ridges or over the entire surface is suggestive of melanoma).6
DISCUSSION RESULTS In all 6 cases of melanoma, the initial sign was longitudinal pigmented streaks in the nail plate, which increased in breadth to finally involve the entire nail plate without deformities (Fig 1, A). Hutchinson’s sign (periungual pigmentation) was also observed in all 6 cases (Fig 1, B). In melanocytic nevus, 15 cases showed partial pigmentation in the nail plates. In 3 cases, the entire nail plate was involved without any deformities. Pigmented macules of the fingertip were seen in the same 3 cases (Fig 2) and in another 2 cases. It is noteworthy that hyponychial pigmentation, which has been generally regarded as a sign of subungual melanoma, is observed in melanocytic nevus. However, the surface profiles of the hyponychial pigmentation of subungual melanomas obtained by the dermatoscope were different from those of melanocytic
Hutchinson’s sign, especially on the hyponychium, is not always evidence of subungual melanoma because it can be seen in both melanoma and melanocytic nevus. However, there is a wide difference in dermatoscopic features between the two. We considered that the dermatoscopic features that distinguish subungual melanoma from melanocytic nevus are linear brushy pattern indicating the benign condition and the diffuse haphazard pattern indicating the malignant condition. We believe that observation of pigmentation on the hyponychium by means of a dermatoscope contributes to the precise differential diagnosis of melanonychia striata with Hutchinson’s sign. REFERENCES 1. Kukita A, Ishihara K. Clinical features and distribution of malignant melanoma and pigmented nevi on the soles of the feet in Japan. J Invest Dermatol 1989;92(Suppl 5):210S-3S.
J AM ACAD DERMATOL VOLUME 44, NUMBER 2
2. Kato T, Usuba Y, Takemasu H, Tagami H. Rapidly growing nail streak resulting in diffuse melanosis of the nail: a possible sign of subungual melanoma in situ. Cancer 1989;64:2191-7. 3. Saida T, Ohshina Y. Clinical and histopathologic characteristics of early lesions of subungual malignant melanoma. Cancer 1989;63:556-60. 4. Akasu R, Sugiyama H, Araki M, Ohtake N, Furue M, Tamaki K. Dermatoscopic and videomicroscopic features of melanocytic plantar nevi. Am J Dermatopathol 1996;18:10-8.
Brief reports 307
5. Oguchi S, Saida T, Koganehira Y, Ohkubo S, Ishihara Y, Kawachi S. Characteristic epiluminescent microscopic features of early malignant melanoma on glabrous skin. Arch Dermatol 1998; 134:563-8. 6. Kawabata Y, Tamaki K. Distinctive dermatoscopic features of acral lentiginous melanoma in situ from plantar melanocytic nevi and their histopathologic correlation. J Cutan Med Surg 1998;2:199-204.