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    "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&#46; It is included in the group of dermal dendritic melanocytic proliferations&#44; characterized by the presence&#44; at least in part&#44; of oval or spindle-shaped cells and dendritic cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2</span></a> The clearly visible&#44; characteristic bluish color is produced by a Tyndall effect&#44; due to the reflection of blue light by melanin in the dermis&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> The lesion may be congenital or acquired&#44; and a number of clinical and histological variants exist&#44; the most frequent being the common and cellular variants&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2</span></a> We present a patient with a common blue nevus at a unusual site&#46;</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&#46; Examination revealed a semicircular&#44; dark-blue macule of 5<span class="elsevierStyleHsp" style=""></span>mm in diameter in the proximal subungual region&#46; Canaliform dystrophy was present across the mid segment of the nail&#44; with dystrophy and fragility of the left border&#46; Hutchinson sign was not observed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; On dermoscopy&#44; a circumscribed&#44; steel-blue colored area with a homogeneous blue pattern was observed&#44; with no other specific dermoscopic structures &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The lesion was excised and histology revealed irregular epidermal hyperplasia with no increase in melanocytes in the basal layer&#59; a proliferation of irregularly arranged&#44; spindle-shaped melanic cells separated by broad bands of dense collagen was present in the papillary and reticular dermis&#44; and abundant melanophages were observed&#46; The melanic cells presented an intensely pigmented cytoplasm that sometimes obscured the nuclear morphology&#46; The nuclei were round&#44; with small or absent nucleoli&#44; with no atypia or mitoses &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</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&#44; spindle-shaped bipolar cells in the dermis or submucosa&#46; The melanocytes present dendritic projections with a variable melanin content&#46; Abundant melanophages are present between the collagen bundles&#46; No cellular atypia or mitoses are observed&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> These lesions can arise on any area of the body surface&#44; most frequently on the limbs or face and more rarely at other sites&#44; such as the oral mucosa&#44; conjunctiva&#44; mucosa of the nose and paranasal sinuses&#44; bronchi&#44; esophagus&#44; stomach&#44; vagina&#44; uterus&#44; penis&#44; prostate&#44; or lymph nodes&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Nine more cases have been published since that time&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;5</span></a> No characteristic pattern has yet been defined&#44; as congenital and acquired lesions have been described on the fingers and toes&#44; on the first or other digits&#44; of the common or cellular variants&#44; with or without longitudinal melanonychia&#44; with or without Hutchinson sign&#44; and stable or showing progressive growth&#46; Seven of the nevi were observed in women and 3 in men&#46; In some cases&#44; the nevus provoked changes in the nail plate&#44; such as clubbing<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> or linear erosions&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> We have now described the eleventh case&#46; Our patient was also a woman&#44; and the nevus was an acquired lesion present on the first finger of her left hand&#44; stable in time&#44; with no Hutchinson sign&#44; and no melanonychia striata&#44; but with longitudinal canaliform dystrophy and lateral fragility of the nail plate&#59; histologically&#44; the lesion was the common variant of blue nevus&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although the clinical and pathological findings made diagnosis simple in this case&#44; the rarity of blue nevus at this site can lead to diagnostic error&#44; as melanoma is more common in the subungual region&#44; accounting for 0&#46;7&#37; to 3&#46;5&#37; of all melanomas&#46;<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&#44; as blue nevi have been described as bluish-white&#44; black&#44; brown&#44; or polychromatic&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Furthermore&#44; melanoma can be difficult to diagnose when it has no pronounced epidermal component&#44; with atypical melanocytes scattered through the epidermis and abundant melanophages in the dermis&#46; If&#44; in addition&#44; the malignant component regresses&#44; only an intense bluish or grayish dermal pigmentation may persist&#44; which could lead to an erroneous diagnosis of blue nevus&#46; Yang et al&#46;<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&#44; but which&#44; after identification of lymph-node metastases&#44; were reinterpreted as subungual melanoma with regression&#46; In these situations&#44; we should remember the rule proposed by Levit et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> to aid diagnosis of subungual melanoma&#44; similar to the well-known ABCDE rule&#58; A for age &#40;most common between the fifth and seventh decades of life&#41; and race &#40;Asian and black or native American&#41;&#44; B for band &#40;brown-black melanonychia broader than 3<span class="elsevierStyleHsp" style=""></span>mm&#44; with irregular borders&#41;&#44; C for changes &#40;rapid changes in size&#44; or dystrophy&#41;&#44; D for digit &#40;1<span class="elsevierStyleHsp" style=""></span>digit more suspicious than several&#41;&#44; E for extension &#40;in reference to Hutchinson sign&#41;&#44; and F for family &#40;relating to a family or personal history of melanoma or dysplastic nevus&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; although subungual blue nevus is very rare&#44; it should always be taken into account to avoid diagnostic error that could lead to irreparable clinical consequences for the patient&#46;</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&#46;</p></span></span>"
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Case and Research Letters
Subungual Blue Nevus
Nevus azul subungueal
C. Fachala, L.C. Pérez-Pérezb, F. Alleguec,
Autor para correspondencia
fallegue@mundo-r.com

Corresponding author.
, S. Calviñoc
a Servicio de Anatomía Patológica, Hospital Álvaro Cunqueiro, Vigo, Spain
b Clínica Pérez & Gavín, Vigo, Spain
c Servicio de Dermatología, Hospital do Meixoeiro, Vigo, Spain
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    "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&#46; It is included in the group of dermal dendritic melanocytic proliferations&#44; characterized by the presence&#44; at least in part&#44; of oval or spindle-shaped cells and dendritic cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2</span></a> The clearly visible&#44; characteristic bluish color is produced by a Tyndall effect&#44; due to the reflection of blue light by melanin in the dermis&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> The lesion may be congenital or acquired&#44; and a number of clinical and histological variants exist&#44; the most frequent being the common and cellular variants&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2</span></a> We present a patient with a common blue nevus at a unusual site&#46;</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&#46; Examination revealed a semicircular&#44; dark-blue macule of 5<span class="elsevierStyleHsp" style=""></span>mm in diameter in the proximal subungual region&#46; Canaliform dystrophy was present across the mid segment of the nail&#44; with dystrophy and fragility of the left border&#46; Hutchinson sign was not observed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; On dermoscopy&#44; a circumscribed&#44; steel-blue colored area with a homogeneous blue pattern was observed&#44; with no other specific dermoscopic structures &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The lesion was excised and histology revealed irregular epidermal hyperplasia with no increase in melanocytes in the basal layer&#59; a proliferation of irregularly arranged&#44; spindle-shaped melanic cells separated by broad bands of dense collagen was present in the papillary and reticular dermis&#44; and abundant melanophages were observed&#46; The melanic cells presented an intensely pigmented cytoplasm that sometimes obscured the nuclear morphology&#46; The nuclei were round&#44; with small or absent nucleoli&#44; with no atypia or mitoses &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</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&#44; spindle-shaped bipolar cells in the dermis or submucosa&#46; The melanocytes present dendritic projections with a variable melanin content&#46; Abundant melanophages are present between the collagen bundles&#46; No cellular atypia or mitoses are observed&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> These lesions can arise on any area of the body surface&#44; most frequently on the limbs or face and more rarely at other sites&#44; such as the oral mucosa&#44; conjunctiva&#44; mucosa of the nose and paranasal sinuses&#44; bronchi&#44; esophagus&#44; stomach&#44; vagina&#44; uterus&#44; penis&#44; prostate&#44; or lymph nodes&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Nine more cases have been published since that time&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;5</span></a> No characteristic pattern has yet been defined&#44; as congenital and acquired lesions have been described on the fingers and toes&#44; on the first or other digits&#44; of the common or cellular variants&#44; with or without longitudinal melanonychia&#44; with or without Hutchinson sign&#44; and stable or showing progressive growth&#46; Seven of the nevi were observed in women and 3 in men&#46; In some cases&#44; the nevus provoked changes in the nail plate&#44; such as clubbing<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> or linear erosions&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> We have now described the eleventh case&#46; Our patient was also a woman&#44; and the nevus was an acquired lesion present on the first finger of her left hand&#44; stable in time&#44; with no Hutchinson sign&#44; and no melanonychia striata&#44; but with longitudinal canaliform dystrophy and lateral fragility of the nail plate&#59; histologically&#44; the lesion was the common variant of blue nevus&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although the clinical and pathological findings made diagnosis simple in this case&#44; the rarity of blue nevus at this site can lead to diagnostic error&#44; as melanoma is more common in the subungual region&#44; accounting for 0&#46;7&#37; to 3&#46;5&#37; of all melanomas&#46;<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&#44; as blue nevi have been described as bluish-white&#44; black&#44; brown&#44; or polychromatic&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Furthermore&#44; melanoma can be difficult to diagnose when it has no pronounced epidermal component&#44; with atypical melanocytes scattered through the epidermis and abundant melanophages in the dermis&#46; If&#44; in addition&#44; the malignant component regresses&#44; only an intense bluish or grayish dermal pigmentation may persist&#44; which could lead to an erroneous diagnosis of blue nevus&#46; Yang et al&#46;<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&#44; but which&#44; after identification of lymph-node metastases&#44; were reinterpreted as subungual melanoma with regression&#46; In these situations&#44; we should remember the rule proposed by Levit et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> to aid diagnosis of subungual melanoma&#44; similar to the well-known ABCDE rule&#58; A for age &#40;most common between the fifth and seventh decades of life&#41; and race &#40;Asian and black or native American&#41;&#44; B for band &#40;brown-black melanonychia broader than 3<span class="elsevierStyleHsp" style=""></span>mm&#44; with irregular borders&#41;&#44; C for changes &#40;rapid changes in size&#44; or dystrophy&#41;&#44; D for digit &#40;1<span class="elsevierStyleHsp" style=""></span>digit more suspicious than several&#41;&#44; E for extension &#40;in reference to Hutchinson sign&#41;&#44; and F for family &#40;relating to a family or personal history of melanoma or dysplastic nevus&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; although subungual blue nevus is very rare&#44; it should always be taken into account to avoid diagnostic error that could lead to irreparable clinical consequences for the patient&#46;</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&#46;</p></span></span>"
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