Nail Dermoscopy

  • Michela StaraceEmail author


Nail dermoscopy was initially used only in the assessment of nail melanocytic lesions, but more recently it is being used for expanded diagnosis of all nail disorders and has become a routine diagnostic instrument. In daily practice, dermoscopy may be a useful tool with which to elucidate common findings about specific diseases in order to reinforce presumptive clinical diagnoses, as well as guide the management and prognoses of different nail diseases. The use of dermoscopy can be applied to all visible parts of the nail unit, but it is also possible to observe the nail matrix, the only non-visible part, in conjunction with intra-operative methods. A good knowledge of the pathogenesis of nail diseases is important in order to know on which part of the nail to focus. The nail is visible as a whole only with 10× magnification, but with a magnification range from 20 to 70×, observation can be improved by moving the lens back and forth and transversally. In most cases nail dermoscopy only permits a better visualization of symptoms already evident to the naked eye. However, in a few diseases, the technique can provide important diagnostic information.

The first part of the chapter, we explain techniques and problems of nail dermoscopy and will help the reader perform this exam on the nails. The second part we show how to identify the normal nail with dermoscopy, followed by sections on the main features of the most commonly encountered nail diseases.

Pictures of the dermoscopic features described in the text are provided, sometimes with the corresponding clinical picture helping to underline the fact the nail dermoscopy is useless without the clinical observation of the signs.


Dermoscopy Onychoscopy Capillaroscopy Onycholysis Pitting Dermatomyositis Systemic lupus erythematous Trachyonychia Splinter hemorrhages Discoloration Proximal margin Capillary Color alterations Melanonychia Management 


  1. 1.
    Cutolo M, Sulli A, Secchi ME, et al. The contribution of capillaroscopy to the differential diagnosis of connective autoimmune diseases. Best Pract Res Clin Rheumatol. 2007;21:1093–108.PubMedGoogle Scholar
  2. 2.
    Hirata SH, Yamada S, Enokihara MY, Di Chiacchio N, et al. Pattern of nail matrix and nail bed of longitudinal melanonychia by intraoperative dermatoscopy. J Am Acad Dermatol. 2011;65:297–303.PubMedGoogle Scholar
  3. 3.
    Hasegawa M. Dermoscopy findings of nail fold capillaries in connective tissue disease. J Dermatol. 2011;38(1):66–70.PubMedGoogle Scholar
  4. 4.
    Cutolo M, Sulli A, Smith V. Assessment microvascular changes in systemic sclerosis diagnosis and management. Nat Rev Rheumatol. 2010;6:578–87.PubMedGoogle Scholar
  5. 5.
    Pizzorni C, Sulli A, Smith V, et al. Capillaroscopy in 2016: new perspective in systemic sclerosis. Acta Rheumatol Port. 2016;41:8–14.Google Scholar
  6. 6.
    Shenavandeh S, Nezhad MZ. Association of nailfold capillary changes with disease activity, clinical and laboratory findings in patients with dermatomyositis. Med J Islam Repub Iran. 2015;29:233.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Dias SS, Isenberg DA. Advanced in systemic lupus erythematous. Medicine. 2014;42(3):126–33.Google Scholar
  8. 8.
    Grossman JM, Kalunian KC. Definition, classification, activity and damage indices. In: Dj W, Hahn BH, editors. Dubois lupus erythematous. Philadelphia., 2002: Lippincott Williams & Wilkins; 2002. p. 19–31.Google Scholar
  9. 9.
    HM B, Abramson SB, Lie JT. Pathology and pathogenesis of vascular injury in systemic lupus erythematous. Interaction of inflammatory cells and activated endothelium. Arthritis Rheum. 1996;39(1):9–22.Google Scholar
  10. 10.
    Hurairah H, Ferro A. The role of the endothelium in the control of vascular function. Int J Clin Pract. 2004;58(2):173–83.PubMedGoogle Scholar
  11. 11.
    Lambova SN, Muller-Ladner U. Capillaroscopic pattern in systemic lupus erythematous and undifferentiated connective tissue disease: what we still have to learn? Rheumatol Int. 2013;33(3):689–95.PubMedGoogle Scholar
  12. 12.
    Piraccini BM, Balestri R, Starace M, et al. Nail digital dermoscopy (Onychoscopy) in the diagnosis of onychomycosis. J Eur Acad Dermatol Venereol. 2013;27(4):509–13.PubMedGoogle Scholar
  13. 13.
    Ronger S, Touzet S, Ligeron C, et al. Dermoscopic examination of nail pigmentation. Arch Dermatol. 2002;138:1327–33.Google Scholar
  14. 14.
    Lencastre A, Lamas A, Sà D, et al. Onychoscopy. Clin Dermatol. 2013;31(5):587–93.PubMedGoogle Scholar
  15. 15.
    Haas N, Henz BM. Pitfall in pigmentation: pseudopods in the nail plate. Dermatol Surg. 2002;28(10):966–7.PubMedGoogle Scholar
  16. 16.
    Criscione V, Telang G, Jellinek N. Onychopapilloma presenting as longitudinal leukonychia. J Am Acad Dermatol. 2010;63:541–2.PubMedGoogle Scholar
  17. 17.
    Piraccini BM, Antonucci A, Rech G, et al. Onychomatricoma: first description in a child. Pediatr Dermatol. 2007;24:46–8.PubMedGoogle Scholar
  18. 18.
    Baran R, Perrin C. Transverse leukonychia of toenails due to repeated microtrauma. Br J Dermatol. 1995;133:267–9.PubMedGoogle Scholar
  19. 19.
    Rigopoulos D, Ralph D. Management of simple brittle nails. Dermatol Ther. 2012;25:596–73.Google Scholar
  20. 20.
    Herschthal J, MP ML, Zaiac M. Management of ungual warts. Dermatol Ther. 2012;25(6):545–50.PubMedGoogle Scholar
  21. 21.
    Maes M, Richert B, de la Brassinne M. Green nail syndrome or chloro-nychia. Rev Med Liege. 2002;57:233–5.PubMedGoogle Scholar
  22. 22.
    Chiriac A, Brzezinski P, Foia L, et al. Chloronychia: green nail syndrome caused by Pseudomons aeruginosa in elderly persons. Clin Interv Aging. 2015;14(10):265–7.Google Scholar
  23. 23.
    Leung LK, Harding J. A chemical mixer with dark-green nails. BMJ Case Rep. 2015;3:2015.Google Scholar
  24. 24.
    Bet DL, Reis AL, Di Chiacchio N, et al. Dermoscopy and onychomycosis: guide nail abrasion for mycological samples. An Bras Dermatol. 2015;90(6):904–6.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Elewski BE, Rich P, Tosti A, et al. Onychomycosis: an overview. J Drugs Dermatol. 2013;12(7):s96–s103.PubMedGoogle Scholar
  26. 26.
    Nakamura RC, Costa MC. Dermatoscopic finding in the most frequent onychopathies: descriptive analysis of 500 cases. Int J Dermatol. 2012;51:483–96.PubMedGoogle Scholar
  27. 27.
    Jesùs-Silva MA, Fernandez-Martinez R, Roldan-Marin R, et al. Dermoscopic patterns in patients with a clinical diagnosis of onychomycosis-result of a prospective study including data of potassium hydroxide (KHO) and culture examination. Dermatol Pract Concept. 2015;5(2):39–44.PubMedPubMedCentralGoogle Scholar
  28. 28.
    Kallis P, Tosti A. Skin Appendage Disord. 2015;1:209–12.Google Scholar
  29. 29.
    Wang YJ, Sun PL. Fungal melanonychia caused by Trichophyton rubrum and the value of dermoscopy. Cutis. 2014;94(3):E5–6.PubMedGoogle Scholar
  30. 30.
    Kilinc Karaarslan I, Acar A, Aytmur D, et al. Dermoscopic features in fungal melanonychia. Clin Exp Dermatol. 2015;40(3):271–8.Google Scholar
  31. 31.
    Braun RP, Baran R, Le Gal FA, et al. Diagnosis and management of nail pigmentation. J Am Acad Dermatol. 2007;56(5):835–47.Google Scholar
  32. 32.
    Piraccini BM, Tosti A. White superficial onychomycosis: epidemiological, clinical and pathological study of 79 patients. Arch Dermatol. 2004;140(6):696–701.PubMedGoogle Scholar
  33. 33.
    Iorizzo M, Dahdah M, Vincenzi C, et al. Videodermoscopy of the hyponychium in nail bed psoriasis. J Am Acad Dermatol. 2008;58(4):714–5.PubMedGoogle Scholar
  34. 34.
    Shelley WB. The spotted lunula. A neglected nail sign associated with alopecia areata. J Am Acad Dermatol. 1980 May;2(5):385–7.PubMedGoogle Scholar
  35. 35.
    de Farias D, Tosti A, Di Chiacchio N, et al. Dermoscopy of nail psoriasis. An Bras Dermatol. 2010;85(1):101–3.PubMedGoogle Scholar
  36. 36.
    Ohtsuka T, Yamakage A, Miyachi Y. Statistical definition of nailfold capillary pattern in patients with psoriasis. Int J Dermatol. 1994;33(11):779–82.PubMedGoogle Scholar
  37. 37.
    Tosti A, Piraccini BM, de Farias D. Nial diseases. Dermatoscopy in clinical practice: beyond pigmented lesions. London: Informa healthcare Ltd; 2010.Google Scholar
  38. 38.
    Errichetti E, Zabotti A, Stinco G, et al. Dermoscopy of nail fold and elbow in the differential diagnosis of early psoriatic arthritis sine psoriasis and early rheumatoid arthritis. J Dermatol. 2016;43:1217–20.PubMedGoogle Scholar
  39. 39.
    Piraccini BM, Dika E, Fanti PA. Nail disorders: practical tips for diagnosis and treatment. Dermatol Clin. 2015;33:185–95.Google Scholar
  40. 40.
    Nakamura R, Broce AAA, Palencia DPC, et al. Dermatoscopy of nail lichen planus. Int J Dermatol. 2013;52:684–7.PubMedGoogle Scholar
  41. 41.
    Friedman P, Sabban EC, Marcucci C, et al. Dermoscopic findings in different clinical variants of lichen planus. Is dermoscopy useful? Dermatol Pract Concept. 2015;5(4):51–5.PubMedPubMedCentralGoogle Scholar
  42. 42.
    Piraccini BM, Bellavista S, Misciali C, et al. Periungual and subungual pyogenic granuloma. Br J Dermatol. 2010;163:941–53.PubMedGoogle Scholar
  43. 43.
    Maehara Lde S, Ohe EM, Enokihara MY, et al. Diagnosis of glomus tumor by nail bed and matrix dermoscopy. An Bras Dermatol. 2010;85:236–8.PubMedGoogle Scholar
  44. 44.
    de Berker D. Erythronychia. Dermatol Ther. 2012;25:603–11.PubMedGoogle Scholar
  45. 45.
    Rai AK. Role of intraoperative dermoscopy in excision of nail unit glomus tumor. Indian Dermatol Online. 2016;7(5):448–50.Google Scholar
  46. 46.
    Perrin C. Tumors of the nail unit. A review. Part I acquired localized longitudinal melanonychia and erythronychia. Am J Dermatopathol. 2013;35:621–36.PubMedPubMedCentralGoogle Scholar
  47. 47.
    Tosti A, Schneider SL, Ramirez-Quizon MN, et al. Clical, dermoscopic and pathologic features of onychopapilloma: a review of 47 cases. J Am Acad Dermatol. 2016;74(3):521–6.PubMedGoogle Scholar
  48. 48.
    Joo HJ, Mr K, Cho BK, et al. Onychomatricoma: a rare tumor of nail matrix. Ann Dermatol. 2016;28(2):237–41.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Lesort C, Debarbieux S, Duru G, et al. Dermoscopic features of onychomatricoma: a study of 34 cases. Dermatology. 2015;231:177–83.PubMedGoogle Scholar
  50. 50.
    Tosti A, Piraccini BM, de Farias DC. Dealing with melanonychia. Semin Cutan Med Surg. 2009;28:49–54.Google Scholar
  51. 51.
    Braun R, Baran R, Saurat J, et al. Surgical pearls: dermatoscopy of the free edge of the nail to determinate the level of the nail plate pigmentation and the location of its probable origin in the proximal or distal nail matrix. J Am Acad Dermatol. 2006;58:714–5.Google Scholar
  52. 52.
    Goettmann-Bonvallott S, André J, Belaich S. Longitudinal melanonychia in children: a clinical and histopathologic study of 40 cases. J Am Acad Dermatol. 1999;41:17–22.Google Scholar
  53. 53.
    Chu DH, Rubin AI. Diagnosis and management of nail disorders in children. Pedriatr Clin. 2014;61:293–308.Google Scholar
  54. 54.
    Richert B, André J. Nail disorders in children: diagnosis and management. Am J Acad Dermatol. 2011;12:101–12.Google Scholar
  55. 55.
    Tosti A, Baran R, Morelli R, et al. Progressive fading of a longitudinal melanonychia due to a nail matrix melanocytic naevus in a child. Arch Dermatol. 1994;130:1076–7.PubMedGoogle Scholar
  56. 56.
    Kikuchi I, Inoue S, Sakaguchi E, et al. Regressing nevoid nail melanosis in childhood. Dermatology. 1993;186:88–93.PubMedGoogle Scholar
  57. 57.
    Murata Y, Kumano K. Dots and lines: a dermoscopic sign of regression of longitudinal melanonychia in children. Cutis. 2012;90:293–6.PubMedGoogle Scholar
  58. 58.
    Lyall D. Malignant melanoma in infancy. J Am Med Assoc. 1967;202:93.Google Scholar
  59. 59.
    Uchiyama M, Minemura K. Two cases of malignant melanoma invyoung persons. Nippon Hifuka Gakkai Zasshi. 1979;89:668.Google Scholar
  60. 60.
    Iorizzo M, Tosti A, Di Chiacchio N, et al. Nail melanoma in children: differential diagnosis and management. Dermatol Surg. 2008;34:974–8.PubMedGoogle Scholar
  61. 61.
    Tosti A, Piraccini BM, Cagalli A, et al. In situ melanoma of the nail unit in children: report pf two cases in fair-skinned Caucasian children. Pediatr Dermatol. 2012;29:79–83.PubMedGoogle Scholar
  62. 62.
    Thomas L, Dalle S. Dermoscopy provides useful information for the management of melanonychia striata. Dermatol Ther. 2007;20:3–10.Google Scholar
  63. 63.
    Di Chiacchio N, Hirata AH, Daniel R, et al. Consensus on melanonychia nail plate dermoscopy. An Bras Dermatol. 2013;88:309–13.PubMedPubMedCentralGoogle Scholar
  64. 64.
    Levit EK, Kagen MH, Scher RK, et al. The ABC rule for clinical detection of subungual melanoma. J Am Acad Dermatol. 2000;42:269–74.Google Scholar
  65. 65.
    Benati E, Riberio S, Longo C, et al. Clinical and dermoscopic clues to differenziate pigmented nail bands: an international dermoscopy society study. J Eur Acad Dermatol Venereol. 2016. Scholar
  66. 66.
    Phan A, Dalle S, Touzet S, et al. Dermoscopic features of acral lentiginous melanoma in a large series of 110 cases in a white population. Br J Dermatol. 2010;162:765–71.PubMedGoogle Scholar
  67. 67.
    Phan A, Touzet S, Dalle S, et al. Acral lentiginous melanoma: a clinicoprognostic study of 126 cases. Br J Dermatol. 2006;155:561–9.PubMedGoogle Scholar
  68. 68.
    Hirata SH, Yamada S, Almeida FA, et al. Dermoscopic examination of the nail bed and matrix. Int J Dermatol. 2006;45:28–30.PubMedGoogle Scholar
  69. 69.
    Sawada M, Yokota K, Matsumoto T, et al. Proposed classification of longitudinal melanonychia based on clinical and dermoscopic criteria. Int J Dermatol. 2014;53:581–5.Google Scholar
  70. 70.
    Ackerman AB. Malignant melanoma in situ: the flat, curable stage of malignant melanoma. Pathology. 1985;17:298–300.PubMedGoogle Scholar
  71. 71.
    Ruben BS. Pigmented lesions of the nail unit: clinical and histopathology features. Semin Cutan Med Surg. 2010;29:148–58.PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Dermatology, Department of Experimental, Diagnostic and Specialty MedicineUniversity of BolognaBolognaItaly

Personalised recommendations