Subungual Hematoma

A 67-year-old woman presents for routine skin exam. The patient had no personal or family history of melanoma, but had surgeries to remove 2 squamous cell cancers on the cheek and forehead. A quick clinical exam revealed a brown and yellow pigmentation in the left great toenail (Figure 1). The patient does not remember the duration of the lesion, and denies any history of recent trauma. 

Upon close inspection with dermoscopy (Figure 2), we noted the pigmentation only involved the distal and middle but not the proximal portion of the nail. There were red, maroon, and dark blue colors in the proximal portion of the pigmentation. Furthermore, there were reddish dots at the peripheral edge of the pigmentation and red lines in the distal portion of the pigmentation. Collectively, these dermoscopic findings were suggestive of subungual hematoma. In the distal portion of the pigmentation, we noted the colors were predominantly yellow and grey, suggesting the diagnosis of onychomycosis. 

No biopsy or fungal culture was performed. Three months later, the subungual hematoma resolved spontaneously
(Figure 3), but signs of onychomycosis were still present. The patient declined treatment with oral lamisil.