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  • Nail melanoma can originate from the nail matrix (typically with longitudinal melanonychia) or the nail bed (typically amelanotic).

  • Nail melanoma is more common in ethnicities with darker skin, such as Native Americans, Africans, and Hispanics.

  • While clinical findings and dermoscopy can help narrow a differential, pathology is the only way to confirm diagnosis of nail melanoma.


  • Remember your ABCDEF of nail melanoma: Age and Race (40–60 yrs; e.g., African, Asian, Hispanic), Border (border irregularities and/or Hutchinson’s sign), Color (variation in color), Digit (melanonychia located on fingernails; single finger nail; thumb), Evolution (changes in shape, color, or size), and Familial History (family and personal history of skin cancer).

  • The gold standard for diagnosis of nail melanoma diagnosis is a full thickness, tangential excision of the entire pigmented nail matrix or nail bed lesions.


  • A more conservative approach for in situ nail melanoma is recommended with an approximate 5-mm wide margin resection of nail apparatus.

  • Invasive subungual melanoma treatment involves amputation of the distal phalanx, sentinel lymph node biopsy, and oncologic referral.


  • While longitudinal melanonychia is one of the most common clinical findings for nail melanoma, recall that up to 25% of cases are amelanotic.

  • Nail melanoma is exceptional in children, with less than 20 cases reported in the literature.


  • To reduce a missed diagnosis, ensure that the full thickness biopsy includes a wide resection margin and contains parts of the nail bed, nail plate, and nail matrix.

  • History of a previous trauma does not exclude diagnosis of melanoma as this is reported in up to 40% of cases.


  • Experts recommend examination of longitudinal melanonychia every 6 months for lesions that have no suspicious findings.

  • Baseline photography and dermoscopy should be used at initial visit and every subsequent follow-up to accurately document changes.


  • Patients should be educated about performing skin self-exams after a bath or shower; specify the importance of examining from head-to-toe and likewise examining each nail individually.

  • Patients with melanocytic activation should be educated about regularly checking their nails and following up with a dermatologist if noticing any irregular changes in color, size, or shape.


Nail melanoma can originate from the nail matrix or the nail bed. Nail matrix melanoma presents in most cases with melanonychia, and it might be difficult for the clinician to differentiate melanoma from other causes of melanocyte proliferation i.e., lentigo and nevus. Nail bed melanoma, also known as subungual melanoma, usually presents as a subungual mass and is often non pigmented (amelanotic melanoma). Nail melanoma has a poor prognosis that is significantly lower than cutaneous melanoma. One of the most significant factors that contributes to outcomes in nail melanoma resides ...

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