Histology Techniques for Nails

  • Beth S. RubenEmail author


Sampling the nail unit for histopathologic analysis is often an important component of the diagnosis of nail disease, whether inflammatory, infectious or neoplastic. While skin biopsy is usually relatively straightforward, the nail unit presents some challenges in this regard. The physical properties of the hard keratin nail plate make biopsy access, specimen submission and processing more complicated. These limitations can greatly affect the quality of the specimen available for interpretation by the pathologist. This chapter will explore some of the techniques commonly used in the analysis of nail unit specimens and offer some ways to improve outcomes to optimize diagnostic success.


Nail unit pathology/histology Nail plate sampling Nail unit biopsy submission and processing Onychomycosis Melanonychia Special stains Immunoperoxidase stains 


  1. 1.
    Ruben BS, McCalmont TH. The importance of attached nail plate epithelium in the diagnosis of nail apparatus melanoma. J Cutan Pathol. 2010;37(10):1028–9. 1027. Scholar
  2. 2.
    Ruben BS. Pigmented lesions of the nail unit: clinical and histopathologic features. Semin Cutan Med Surg. 2010;29(3):148–58. Scholar
  3. 3.
    Richert B, Theunis A, Norrenberg S, André J. Tangential excision of pigmented nail matrix lesions responsible for longitudinal melanonychia: evaluation of the technique on a series of 30 patients. J Am Acad Dermatol. 2013;69(1):96–104. Scholar
  4. 4.
    Reinig E, Rich P, Thompson CT. How to submit a nail specimen. Dermatol Clin. 2015;33(2):303–7. Scholar
  5. 5.
    Chang A, Wharton J, Tam S, Kovich OI, Kamino H. A modified approach to the histologic diagnosis of onychomycosis. J Am Acad Dermatol. 2007;57(5):849–53. Scholar
  6. 6.
    Lewin K, DeWit SA, Lawson R. Softening techniques for nail biopsies. Arch Dermatol. 1973;107(2):223–4.CrossRefGoogle Scholar
  7. 7.
    Orchard GE, Torres J, Sounthararajah R. Use of softening agents to improve the production of formalin-fixed, paraffin-embedded sections of nail tissue: an assessment. Br J Biomed Sci. 2008;65(2):68–70.CrossRefGoogle Scholar
  8. 8.
    Nazarian RM, Due B, Deshpande A, Duncan LM, Misdraji J. An improved method of surgical pathology testing for onychomycosis. J Am Acad Dermatol. 2012;66(4):655–60.CrossRefGoogle Scholar
  9. 9.
    Household Products Database – Health and Safety Information on Household Products. Accessed 18 Sept 2016.
  10. 10.
    Alers JC, Krijtenburg PJ, Vissers KJ, van Dekken H. Effect of bone decalcification procedures on DNA in situ hybridization and comparative genomic hybridization. EDTA is highly preferable to a routinely used acid decalcifier. J Histochem Cytochem Off J Histochem Soc. 1999;47(5):703–10.CrossRefGoogle Scholar
  11. 11.
    Choi S-E, Hong SW, Yoon SO. Proposal of an appropriate decalcification method of bone marrow biopsy specimens in the era of expanding genetic molecular study. J Pathol Transl Med. 2015;49(3):236–42. Scholar
  12. 12.
    Fleckman P, Omura EF. Histopathology of the nail. Adv Dermatol. 2001;17:385–406.PubMedGoogle Scholar
  13. 13.
    Suarez SM, Silvers DN, Scher RK, Pearlstein HH, Auerbach R. Histologic evaluation of nail clippings for diagnosing onychomycosis. Arch Dermatol. 1991;127(10):1517–9.CrossRefGoogle Scholar
  14. 14.
    Sagher F. Histologic examinations of fungous infections of the nails. J Invest Dermatol. 1948;11(5):337–57.CrossRefGoogle Scholar
  15. 15.
    Scher RK, Ackerman AB. Subtle clues to diagnosis from biopsies of nails. Histologic differential diagnosis of onychomycosis and psoriasis of the nail unit from cornified cells of the nail bed alone. Am J Dermatopathol. 1980;2(3):255–6.CrossRefGoogle Scholar
  16. 16.
    Lawry MA, Haneke E, Strobeck K, Martin S, Zimmer B, Romano PS. Methods for diagnosing onychomycosis: a comparative study and review of the literature. Arch Dermatol. 2000;136(9):1112–6.CrossRefGoogle Scholar
  17. 17.
    Karimzadegan-Nia M, Mir-Amin-Mohammadi A, Bouzari N, Firooz A. Comparison of direct smear, culture and histology for the diagnosis of onychomycosis. Australas J Dermatol. 2007;48(1):18–21. Scholar
  18. 18.
    Weinberg JM, Koestenblatt EK, Tutrone WD, Tishler HR, Najarian L. Comparison of diagnostic methods in the evaluation of onychomycosis. J Am Acad Dermatol. 2003;49(2):193–7.CrossRefGoogle Scholar
  19. 19.
    D’Hue Z, Perkins SM, Billings SD. GMS is superior to PAS for diagnosis of onychomycosis. J Cutan Pathol. 2008;35(8):745–7. Scholar
  20. 20.
    Barak O, Asarch A, Horn T. PAS is optimal for diagnosing onychomycosis. J Cutan Pathol. 2010;37(10):1038–40. Scholar
  21. 21.
    Reza Kermanshahi T, Rhatigan R. Comparison between PAS and GMS stains for the diagnosis of onychomycosis. J Cutan Pathol. 2010;37(10):1041–4. Scholar
  22. 22.
    Perrin C, Baran R. Longitudinal melanonychia caused by trichophyton rubrum. Histochemical and ultrastructural study of two cases. J Am Acad Dermatol. 1994;31(2 Pt 2):311–6.CrossRefGoogle Scholar
  23. 23.
    Finch J, Arenas R, Baran R. Fungal melanonychia. J Am Acad Dermatol. 2012;66(5):830–41. Scholar
  24. 24.
    Gupta AK, Drummond-Main C, Cooper EA, Brintnell W, Piraccini BM, Tosti A. Systematic review of nondermatophyte mold onychomycosis: diagnosis, clinical types, epidemiology, and treatment. J Am Acad Dermatol. 2012;66(3):494–502. Scholar
  25. 25.
    Burkhart CN, Burkhart CG, Gupta AK. Dermatophytoma: recalcitrance to treatment because of existence of fungal biofilm. J Am Acad Dermatol. 2002;47(4):629–31.CrossRefGoogle Scholar
  26. 26.
    Carney C, Tosti A, Daniel R, et al. A new classification system for grading the severity of onychomycosis: onychomycosis severity index. Arch Dermatol. 2011;147(11):1277–82. Scholar
  27. 27.
    Hafner J, Haenseler E, Ossent P, Burg G, Panizzon RG. Benzidine stain for the histochemical detection of hemoglobin in splinter hemorrhage (subungual hematoma) and black heel. Am J Dermatopathol. 1995;17(4):362–7.CrossRefGoogle Scholar
  28. 28.
    Amin B, Nehal KS, Jungbluth AA, et al. Histologic distinction between subungual lentigo and melanoma. Am J Surg Pathol. 2008;32(6):835–43. Scholar
  29. 29.
    Ruben BS. Pigmented lesions of the nail unit. Semin Cutan Med Surg. 2015;34(2):101–8. Scholar
  30. 30.
    Theunis A, Richert B, Sass U, Lateur N, Sales F, André J. Immunohistochemical study of 40 cases of longitudinal melanonychia. Am J Dermatopathol. 2011;33(1):27–34. Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Dermatology/DermatopathologyUniversity of CaliforniaSan FranciscoUSA
  2. 2.Dermatology/DermatopathologyPalo Alto Medical FoundationPalo AltoUSA

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