Splinter hemorrhage - Nail and Distal Digit
Overall, estimated prevalence for splinter hemorrhages is about 19%, and they are more common in men than women and in patients of African descent than those of Northern European descent. Fingernails are more often involved than toenails. Typically, only one fingernail is involved. In manual workers, splinter hemorrhages are most common on the right thumbnail and the right second fingernail, presumably due to trauma.
Besides occurring secondary to external manual trauma, splinter hemorrhages may be seen in the setting of a wide variety of dermatologic and systemic conditions. In addition to infective endocarditis, other reported associations are nail psoriasis, nail lichen planus, antiphospholipid syndrome, thromboangiitis obliterans, vasculitis, meningococcemia, high altitude, and medications. Splinter hemorrhages present in 60%-70% of patients taking multikinase inhibitors, typically in the first 2 months of treatment. Other associations include onychomatricoma, onychopapilloma, and tuberous sclerosis.
Pathophysiology is not completely understood. It is thought that splinter hemorrhages are caused by disturbance of nail bed spiral arteries and become longitudinal due to the natural grooves and ridges of the nail plate.
L60.8 – Other nail disorders
91608003 – Splinter hemorrhage
Differential Diagnosis & Pitfalls
- Subungual hematoma – Dermoscopy and a nail clipping can be used to rule out a subungual hematoma.
- Glomus tumor – X-ray or ultrasound / MRI can be used to rule out a glomus tumor.
- Nail squamous cell carcinoma – This may present as longitudinal erythronychia in the early stages. If malignancy is suspected, a nail biopsy is required.
- Amelanotic melanoma – This may also present as longitudinal erythronychia in the early stages. A low threshold for biopsy of an evolving area of erythronychia is key.
- Subungual red comets of tuberous sclerosis