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Longitudinal Melanonychia

Melanonychia (longitudinal streaks) is characterized by the presence of a pigmented stripe, tan, brown, or black within the length of the nail bed and occurs most frequently in black and dark skinned individuals as well as women of any race. In Caucasian (white) patients, this condition may reflect pituitary tumors, effects of cytotoxic drugs, malnutrition with vitamin B12 deficiency, Addison's disease or Hutchinson’s sign, an underlying subungual melanoma with pigmentation in progress proximally onto the nail fold.

Longitudinal Melanonychia, also known as Melanonychia Striata results from deposition of melanin in the nail plate from a variety of causes. Fungal infection can be considered as the cause of this disorder but it must be differentiated from the Melanonychia caused by melanocytic lesions in people with subungual malignant melanoma, especially if noted in a single nail, and is associated with scleroderma in rare cases.

Patients develop characteristic signs and symptoms; abnormalities of the cornea, cataracts and astigmatism along with sideways bent fingers, clubfoot, unusual neck bones, hip dislocation, poorly developed shoulder blades, or scoliosis. Abnormal collagen deposition in the glomeruli may be the cause of the nephropathy associated with NPS. Also, a genetic abnormality seems to lead to altered connective tissue metabolism with widespread structural defects in collagen.

This longitudinal condition is paradoxical as increased skin pigmentation is common in the latter disease. In children, this can be caused by antibiotics, chemotherapeutic agents or other drugs as consequence of onychomycosis, infections, pseudomonas, psoriasis or other skin diseases. The time interval between the beginning of any therapy and the first evident signs of nail pigmentation depend on the rate of nail growth.

In the treatment of Longitudinal Melanonychia the hyperpigmentation of the skin and nails induced by chemotherapy is reversible and most commonly seen with drugs like doxorubicin, cyclophosphamide and hydroxyurea. This condition must be treated as soon as it is recognized and patients may obtain relief with treatments such as manipulation or surgery, required to correct hip dislocation, cataracts treated surgically and medical treatment at early signs of glaucoma to prevent progression of the disease and eventual blindness.

Longitudinal Melanonychia needs to be evaluated by biopsy to corroborate if it is benign finding rather than a sign of subungual melanoma. In fact, melanoma has to be always part of the differential diagnosis since it is not possible to accurately determine the cause of the hyperpigmentation based exclusively on histologic data and clinical appearance alone.

Those patients that receive a kidney transplant do not develop Nail Patella renal complications in their new kidney but they should be advised to pursue extra medical care including regular urinalysis and special eye exams to prevent Longitudinal Melanonychia. Children with Nail Patella Syndrome have to be screened for scoliosis and, in all cases biopsy is a good method for diagnosis of pigment in the nail unit.

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