Case and Research Letters
Subungual Blue Nevus
Nevus azul subungueal
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Fachal, L.C. Pérez-Pérez, F. Allegue, S. Calviño" "autores" => array:4 [ 0 => array:3 [ "nombre" => "C." "apellidos" => "Fachal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "L.C." "apellidos" => "Pérez-Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:4 [ "nombre" => "F." "apellidos" => "Allegue" "email" => array:1 [ 0 => "fallegue@mundo-r.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 3 => array:3 [ "nombre" => "S." "apellidos" => "Calviño" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Álvaro Cunqueiro, Vigo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Clínica Pérez & Gavín, Vigo, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital do Meixoeiro, Vigo, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nevus azul subungueal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1027 "Ancho" => 1138 "Tamanyo" => 98732 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Circumscribed area of homogeneous bluish color.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Blue nevus is a benign pigmented melanic lesion formed of intensely pigmented dendritic melanocytes located in the dermis. It is included in the group of dermal dendritic melanocytic proliferations, characterized by the presence, at least in part, of oval or spindle-shaped cells and dendritic cells.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a> The clearly visible, characteristic bluish color is produced by a Tyndall effect, due to the reflection of blue light by melanin in the dermis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> The lesion may be congenital or acquired, and a number of clinical and histological variants exist, the most frequent being the common and cellular variants.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a> We present a patient with a common blue nevus at a unusual site.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A woman aged 35 years was seen for evaluation of a dark spot that had been present under the nail of the first finger of her left hand for approximately 5 years. Examination revealed a semicircular, dark-blue macule of 5<span class="elsevierStyleHsp" style=""></span>mm in diameter in the proximal subungual region. Canaliform dystrophy was present across the mid segment of the nail, with dystrophy and fragility of the left border. Hutchinson sign was not observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). On dermoscopy, a circumscribed, steel-blue colored area with a homogeneous blue pattern was observed, with no other specific dermoscopic structures (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The lesion was excised and histology revealed irregular epidermal hyperplasia with no increase in melanocytes in the basal layer; a proliferation of irregularly arranged, spindle-shaped melanic cells separated by broad bands of dense collagen was present in the papillary and reticular dermis, and abundant melanophages were observed. The melanic cells presented an intensely pigmented cytoplasm that sometimes obscured the nuclear morphology. The nuclei were round, with small or absent nucleoli, with no atypia or mitoses (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Common blue nevus is a benign neoplasm characterized by a proliferation of elongated, spindle-shaped bipolar cells in the dermis or submucosa. The melanocytes present dendritic projections with a variable melanin content. Abundant melanophages are present between the collagen bundles. No cellular atypia or mitoses are observed.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> These lesions can arise on any area of the body surface, most frequently on the limbs or face and more rarely at other sites, such as the oral mucosa, conjunctiva, mucosa of the nose and paranasal sinuses, bronchi, esophagus, stomach, vagina, uterus, penis, prostate, or lymph nodes.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The first description of a subungual blue nevus with its histological findings was published by Vidal et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Nine more cases have been published since that time.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4,5</span></a> No characteristic pattern has yet been defined, as congenital and acquired lesions have been described on the fingers and toes, on the first or other digits, of the common or cellular variants, with or without longitudinal melanonychia, with or without Hutchinson sign, and stable or showing progressive growth. Seven of the nevi were observed in women and 3 in men. In some cases, the nevus provoked changes in the nail plate, such as clubbing<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> or linear erosions.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> We have now described the eleventh case. Our patient was also a woman, and the nevus was an acquired lesion present on the first finger of her left hand, stable in time, with no Hutchinson sign, and no melanonychia striata, but with longitudinal canaliform dystrophy and lateral fragility of the nail plate; histologically, the lesion was the common variant of blue nevus.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although the clinical and pathological findings made diagnosis simple in this case, the rarity of blue nevus at this site can lead to diagnostic error, as melanoma is more common in the subungual region, accounting for 0.7% to 3.5% of all melanomas.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> This diagnostic confusion is more likely in those cases in which the blue color is clinically or dermoscopically less clear, as blue nevi have been described as bluish-white, black, brown, or polychromatic.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Furthermore, melanoma can be difficult to diagnose when it has no pronounced epidermal component, with atypical melanocytes scattered through the epidermis and abundant melanophages in the dermis. If, in addition, the malignant component regresses, only an intense bluish or grayish dermal pigmentation may persist, which could lead to an erroneous diagnosis of blue nevus. Yang et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> published 2 cases of subungual melanoma in which the histopathological findings were indistinguishable from blue nevus, but which, after identification of lymph-node metastases, were reinterpreted as subungual melanoma with regression. In these situations, we should remember the rule proposed by Levit et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> to aid diagnosis of subungual melanoma, similar to the well-known ABCDE rule: A for age (most common between the fifth and seventh decades of life) and race (Asian and black or native American), B for band (brown-black melanonychia broader than 3<span class="elsevierStyleHsp" style=""></span>mm, with irregular borders), C for changes (rapid changes in size, or dystrophy), D for digit (1<span class="elsevierStyleHsp" style=""></span>digit more suspicious than several), E for extension (in reference to Hutchinson sign), and F for family (relating to a family or personal history of melanoma or dysplastic nevus).</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, although subungual blue nevus is very rare, it should always be taken into account to avoid diagnostic error that could lead to irreparable clinical consequences for the patient.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fachal C, Pérez-Pérez LC, Allegue F, Calviño S. Nevus azul subungueal. Actas Dermosifiliogr. 2018;109:88–90.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 789 "Ancho" => 1138 "Tamanyo" => 144715 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Semicircular bluish-black macule and nail dystrophy.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1027 "Ancho" => 1138 "Tamanyo" => 98732 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Circumscribed area of homogeneous bluish color.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 853 "Ancho" => 1138 "Tamanyo" => 489403 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Intensely pigmented bipolar melanocytes in the dermis, between thick collagen fibers. Hematoxylin and eosin, original magnification<span class="elsevierStyleHsp" style=""></span>x200.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Blue nevi and related lesions: A review highlighting atypical and newly described variants, distinguishing features and diagnostic pitfalls" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. Murali" 1 => "S.W. McCarthy" 2 => "R.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 22 | 9 | 31 |
| 2024 October | 138 | 41 | 179 |
| 2024 September | 142 | 32 | 174 |
| 2024 August | 193 | 58 | 251 |
| 2024 July | 155 | 44 | 199 |
| 2024 June | 145 | 31 | 176 |
| 2024 May | 131 | 46 | 177 |
| 2024 April | 140 | 27 | 167 |
| 2024 March | 140 | 34 | 174 |
| 2024 February | 122 | 35 | 157 |
| 2024 January | 172 | 31 | 203 |
| 2023 December | 125 | 16 | 141 |
| 2023 November | 117 | 30 | 147 |
| 2023 October | 122 | 23 | 145 |
| 2023 September | 128 | 24 | 152 |
| 2023 August | 108 | 22 | 130 |
| 2023 July | 126 | 30 | 156 |
| 2023 June | 97 | 25 | 122 |
| 2023 May | 150 | 29 | 179 |
| 2023 April | 101 | 16 | 117 |
| 2023 March | 114 | 33 | 147 |
| 2023 February | 96 | 30 | 126 |
| 2023 January | 81 | 26 | 107 |
| 2022 December | 77 | 36 | 113 |
| 2022 November | 50 | 29 | 79 |
| 2022 October | 51 | 24 | 75 |
| 2022 September | 37 | 46 | 83 |
| 2022 August | 27 | 38 | 65 |
| 2022 July | 43 | 38 | 81 |
| 2022 June | 31 | 21 | 52 |
| 2022 May | 102 | 35 | 137 |
| 2022 April | 111 | 56 | 167 |
| 2022 March | 118 | 46 | 164 |
| 2022 February | 94 | 25 | 119 |
| 2022 January | 112 | 38 | 150 |
| 2021 December | 67 | 31 | 98 |
| 2021 November | 86 | 36 | 122 |
| 2021 October | 80 | 50 | 130 |
| 2021 September | 75 | 40 | 115 |
| 2021 August | 75 | 42 | 117 |
| 2021 July | 80 | 39 | 119 |
| 2021 June | 71 | 32 | 103 |
| 2021 May | 54 | 49 | 103 |
| 2021 April | 133 | 89 | 222 |
| 2021 March | 86 | 30 | 116 |
| 2021 February | 58 | 31 | 89 |
| 2021 January | 33 | 22 | 55 |
| 2020 December | 59 | 26 | 85 |
| 2020 November | 32 | 26 | 58 |
| 2020 October | 28 | 10 | 38 |
| 2020 September | 35 | 16 | 51 |
| 2020 August | 20 | 18 | 38 |
| 2020 July | 31 | 16 | 47 |
| 2020 June | 40 | 37 | 77 |
| 2020 May | 19 | 13 | 32 |
| 2020 April | 34 | 14 | 48 |
| 2020 March | 27 | 22 | 49 |
| 2020 February | 3 | 1 | 4 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 8 | 0 | 8 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 6 | 0 | 6 |
| 2019 May | 4 | 1 | 5 |
| 2019 April | 2 | 0 | 2 |
| 2019 March | 4 | 0 | 4 |
| 2019 January | 27 | 0 | 27 |
| 2018 December | 6 | 0 | 6 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 3 | 0 | 3 |
| 2018 February | 64 | 27 | 91 |
| 2018 January | 167 | 34 | 201 |
| 2017 December | 16 | 20 | 36 |
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