nail biopsy

DR.YUGANDAR

NAIL BIOPSY

Nail Biopsy

Two Primary reasons to perform biopsy- Confirm diagnosis of disease- Remove neoplasm or correct deformity (d/t

pain )

Nail Biopsy

Site : Proximal to Distal Growth of nail ,Matrix biopsies performed with long axis of biopsy in transverse direction to avoid scar,It Causes a split in nail

Nail Biopsy

Indications:

- Differentiate b/w inflammatory & infective

disorders affecting nail unit

- To establish diagnosis of one or 20- nail

dystrophy

Nail Biopsy

- To establish cause of longitudinal pigmented

streaks

- Differentiate Subungual hematoma &

Malignat melanoma

Nail Biopsy

Indications:

- Differentiate benign & malignant tumours

- To identify the cause of pain ( eg Glomus

tumour )

Contraindications:

- Severe uncontrolled diabete

- Severe Peripheral vascular diseases

Nail Biopsy

Biopsies of nail :- Nail Plate- Nail bed- Nail Matrix- Nail fold- Nail unit Biopsy ( Combined Biopsy of

LNF,Lateral Nail Matrix & PNF )

Different types of nail biopsy

Site & technique of nail biopsy for common nail disorders

All biopsy or excision should be taken down to bone ( No subcutaneous tissue in nail)

Relationship of nail matrix & surface

Proximal part of nail matrix forms dorsal surface, distal portion of matrix forms ventral portion

Surgery to distal matrix is preferable to proximal matrix

Nail Biopsy

Patient Evaluation Prior to Nail Biopsy:

History:

- Medical H/O- DM,CTD,BD,PVD,HTN

- Drug H/O- Use of

Anticoagulants,Salicylates,NSAIDs,Prev

ious diagnostic tests,

Nail Biopsy

- Cutaneous H/O-

H/O Nail Condition

(Duration,Progression,Exposure,Trauma)

Previous Malignancies,Fungal,Bacterial

infections,Psoriasis,Lichen planus

Occupation,Hobbies

Nail Biopsy

Examination:

- All 20 nails,good lighting & magnification

- Mucous membranes,hair & Scalp

- Perpheral pulses

Nail Biopsy

Laboratory tests:

- X-ray,Mycology,Microbiology

Nail Biopsy

Patient Evaluation Prior to Nail Biopsy:

Procedure & Risk discussion:-Possibility of permanent dystrophy- Possibility of no diagnosis-Length of time for nail to regrow-Bleeding,Pain,Infection

Nail Biopsy

Reaons : Why Matrix shoudn’t be

damaged in nail biopsy

- Nail thickness is directly related to

length or size of nail matrix

- The matrix is centre of nail formation &

the source of nail plate

- Nail growth is a direct function of rate

of turnover of matrix cells

Principles Guiding Nail Biopsy

When information obtained from other

sites like skin biopsy,avoid biopsy of

nail matrix

Avoid transecting nail matrix to prevent

split nail deformity

Suture defects in nail bed possible

Perform distal rather than proximal

nail matrix biopsy

Retain distal curvature of nail

Nail Biopsy

Instruments:

- Nail Eleavators,Freer Eleavators

- Pointed scissors,Curved iris scissors

- 30 gauge needles,Luer lok syringe

- Double-action nail splitter

- Single or double skin hooks

Nail Biopsy

- Penrose drains

- English nail splitter,clippers

- Disposable biopsy punches

Nail Biopsy Instruments

Double action nail nipper & Freer Eleavator on left side of tray

Fine Curved ( Castro Veijo’s ) scissors,Fine Curved ( Jewellers ) forceps,Nail spatula ,Nail splitter & Disposable Biopsy Punches

Freer Eleavator – Proximal nail Plate avulsion

English Nail splitter used to divide nail plate prior nail avulsion

Nail Biopsy Instruments

Nail Biopsy

Anesthesia:

Local anesthetic administered with via 30

gauge needle on Luer-Lok syringe

Anesthetics used :

- 2% lidocaine,

- Ropivacaine ,Bupivacaine used for regional

blocks

Nail Biopsy

Lidocaine with adreanaline combination for digital anesthesia still controversy

Nail Biopsy

Digital Anesthesia:

Distal nail blocks

1. Distal digital block

2. Distal anesthesia through PNF

3. Distal anesthesia through hyponychium

Nail Biopsy

Proximal digital blocks

Transthecal digital blocks

Regional blocks

Nail Biopsy

Most common form of anesthesia is Ring

Block ( Digital nerve block )

Injecting 1-2 ml at base of each digit on

dorsolateral aspect

> 5 ml anesthetic impair Circulation of digits

Nail Biopsy

After 10 mins injection,efficacy of block can be

assessed at digit tip with help of same needle

If anesthesia is incomplete,It can be

supplemented by small local injection of

anesthetic at site of biopsy or surgery ( it may

increase tissue turgor,fine manipulation

difficult )

Nail Biopsy

Different Digital sites of injection for Ring block

Site of Lidocaine injections for wing & digital block

Nail Biopsy

Distal Digital Block:

- Needle inserted 2-3mm proximal to junction

of PNF & LNF

- After raising skin to minimize pain,needle

inserted vertically down toward ventral

aspect

- While doing so 0.5 – 1 ml anesthetic agent

injected to cover dorsal & ventral digital

nerves

Advantages Disadvantages

Immediate effect < 1 min

Low risk of neurovascular compromise

Induces compression hemostasis

Local injectionRelatively painfulMay cause

inadequate coverage & swelling of surgical field in large surgeries

Nail Biopsy Distal Digital Block

Distal Digital Block

Median Distal Block

Nail Biopsy

Proximal Digital block:

- Needle is introduced at base of digit & wheal

raised

- Needle pushed in ventral direction injecting

anesthetic agent at dorsal & ventral digital

nerves

- 1 ml for each nerve of thumb,2ml for toe

- It takes 10-15 mins for full effect

Dorsal View Ventral View

Proximal Digital block

Nail Biopsy - Drapping

-With sterile glove on involved hand

- Tip of glove is cut off, finger that is

undergoing surgery

- Remaining open finger of glove then rolled

back down digit,Provides tourniquet when

reaches proximal part of finger

- Toe nail surgery foot is draped with

sterile towels secured by towel clamps

Tourniquet

Sterile Glove used as Tourniquet

Tourniquet

Ischaemia can be tolerated in a normal digit

for 20 min

The standard tourniquet for local anaesthetic

is the Penrose drain

An alternative is Sterile glove

Penrose drain Sterile glove with artery forceps

Tourniquet

Patterns of Nail Biopsy

Nail Avulsion

Nail bed biopsy

Matrix biopsy

1. Lateral Longitudinal nail biopsy

2. Transverse matrix biopsy

3.Matrix shave

Patterns of Nail Biopsy

Nail fold biopsy 1. Proximal Nail fold Biopsy 2. Transverse Nail fold biopsy 3. Crescentric Nail fold biopsy 4. Focal Nail fold biopsy

Nail Avulsion

Examine underlying tissues or to provide temporary relief in cases of soft-tissue trauma

Distal or ring block,Nail elevator are used,For a partial avulsion nail splitters are needed

Proximal hemiavulsion of nail plate Procedure:

1. The origin of the nail and its proximal lateral

aspects are undermined with a septum elevator.

2. In nails with a shallow lateral nail fold, a nail

splitter may be inserted and the nail transversely

bisected.

3. In nails with a deep lateral nail fold, a deep

transverse score is placed with a scalpel across

the nail halfway along its length.

4. The septum elevator is then fully inserted

through the transverse score to loosen,elevate

proximal nail.

Nail Avulsion

After Partial Nail Avulsion Nail bed can be seen & biopsed along longitudinal access

Nail Avulsion

Freer Eleavator inserted under nail plate

Loosened nail plate is grabed with hemostat & removed

Nail Avulsion

Digital block has been performed

Nail Avulsion

Apply rubber band

Nail Avulsion

Release eponychium and lateral side

Nail Avulsion

Cut complete nail (proceed under the cuticle), when the proximal edge is cut a 'give' can be felt

Nail Avulsion

Grasp as much nailplate into needledriver or hemostat

Nail Avulsion

Continue cutting undernath cuticle

Nail Avulsion

Remove nailplate by gentle traction and rotating outward

Distal Nail Avulsion Proximal Nail Avulsion

Nail Avulsion

Nail Biopsy

Nail Plate Biopsy:- It is performed using nail nipper for distal

part & 3- 4mm atleast - Nail plate may get suck in the punch- look

& remove it- Differentiate b/w onychomycosis and

psoriasis- Wounds no scarring

Removal of Nail Plate

Nail Biopsy

Nail Bed Biopsy:- Partial Nail plate avulsion is performed with

a 4mm punch or nail plate lifting- 3mm punch is used to take sample from nail

bed- Punch is moved deep,till it touches

periosteum,Base is separated by iris scissors

- Larger samples: Elliptical excision with a maximum width of 3mm taken with long axis of incision along long axis of nail

Nail Bed Biopsy

An alternative is to employ a double punch technique

6-mm hole can be made in the nail plate with a biopsy punch over the area of nail bed to be examined, and the nail bed sampled using a smaller punch.

Closure is not possible. After complete haemostasis, the original disc of nail plate can be returned after soaking in antiseptic

Nail Bed Biopsy

It may reattach or at least provide a natural dressing during the early healing phase.

No Scarring from biopsy

Nail Bed Biopsy

Suspected nail bed glomus tumour

Nail Bed Biopsy

Subungual glomus tumour seen as a bluish mass after nail plate avulsion

Nail Bed Biopsy

Excision of tumour done

Nail bed incisons are oriented longitudinally

Nail Bed Biopsy

> 3 mm size needs to be sutured

Punch Biopsy Fusiform Biopsy

Nail Bed Biopsy

Nail Bed Biopsy

After digital block with NPA or without NPA

3 mm Punch Biopsy obtained by passing vertially down until periosteum

Specimen is free with iris scissors

Nail Bed Biopsy- Double Punch Technique

After digital block 5-6 mm Punch is used to remove nail plate

3 mm punch used to obtain specimen in centre of previously created window

Nail Biopsy

Nail Matrix Biopsy:- Proximal Nail avulsion has to be performed

to visualize the matrix- The matrix sample is taken using a 3mm

punch or Longitudinal elliptical sample oriented horizontially to long axis of digit

Nail Matrix Biopsy

Nail Matrix Biopsy

After nail plate avulsion,releasing incisions in the PNF

The PNF is retracted with skin hooks to visualize of nail matrix

The PNF is replaced & sutured with steri strips

Nail Matrix Biopsy

Lateral incisions made at jn of PNF & LNF

PNF is lifted up & retracted with stay sutures

Adequate sized punch driven down up to periosteum

Punch biopsy specimen lifted up

Lateral Longitudinal Nail biopsy

It is definitive method for sampling all the tissues

of the nail unit

Incision starts in the lateral nail sulcus b/w the

nail & nail fold.distally upto distal

groove,Proximally the incision upto the first of the

transverse skin markings of the distal

interphalangeal joint

Medial margin of the ellipse is formed by an

incision

through the nail plate, which has been softened

by an antiseptic soak


Both incisions are down to bone and

separated by 3 mm at the widest point. The

specimen is separated from its attachment

from the distal point proximally

The nail can be lifted at the free edge with

forceps, allowing the bottom of the

specimen to be released with curved iris

scissors

A 3/0 or 4/0 monofi lament for suture


A Large Lateral Longitudinal biopsy is closed with sutures designed to reconstruct lateral nail fold


Area to be excised outlined,The incision is linear medially & curved laterally


The incision is carried down to periosteum & tissue is lifted up with sharp scissors

Lateral Longitudinal Nail biopsyThe separated specimen forhistopathologic examination

Lateral Longitudinal Nail biopsyThe defect is sutured back


Lateral portions of nail unit excised enbloc

Includes Hyponychium,nail plate,nail matrix,nail bed & PNF

Transverse Matrix biopsy

The PNF is refl ected following an oblique

incision at the junction with the LNFs &

gentle separation of the PNF from the

dorsal aspect of the nail plate

The matrix is then visualized by performing

a proximal hemi-avulsion


A thin ellipse is taken from the distal matrix

with the distal margin of the excision

matching the shape of the lunula


Crescentic or narrow elliptical transverse matrix biopsy, which can be performed after removal of the proximal half of the nail plate alone.

Matrix shave or tangential biopsy

A diagnostic shave biopsy from nail matrix in longitudinal melanonychia

Matrix exposed,with identification of origin of melanonychia

The origin is then scored with a scalpel, 1 mm

beyond the edge of the pathology It can also represent an excision

specimenThe nail plate is replaced to prevent

contact between the wound and ventral aspect of the nail fold

suture repair is not required.

Matrix shave or tangential biopsy

Proximal nail fold biopsy

Biopsy the PNF to investigate a local dermatosis, connective tissue disease or focal tumour

Preservation of the symmetry & curvature of the proximal nail fold is a priority

A distal wing block should be avoided, as the tissues will become turgid and difficult to manipulate.

Proximal nail fold biopsy

Method of removing small lesion from the PNF

Transverse nail fold biopsy

A transverse ellipse (for connective tissue disease), a 2-mm punch (far from the free edge) or a shave biopsy are simple nail fold procedures

The transverse ellipse and punch biopsies are down to the dorsal aspect of the nail plate

The matrix may require protection from cutting trauma and this can be achieved

by inserting a septum elevator between the nail fold and the nail.

Transverse nail fold biopsy

Postoperatively, a thin line may remain in the nail fold after the transverse biopsy

these techniques leave little or no scarring. There is no nail plate change.

Crescentic nail fold biopsy

crescentic incision is performed just proximal to the cuticle with the blade angled to direct trauma away from the proximal matrix

matrix protection provided by inserting a septum elevator

Distal fraction of the proximal nail fold (including the cuticle) can be removed, although the width of the specimen should not exceed 4–5 mm in the midline


The wound heals by secondary intention and a new cuticle usually reforms, depending upon the original problem

Excision of chronic paronychia resistant to routine therapy

Excision of digital mucus cysts occupying the most distal margin of the nail fold


Crescentic shave of distal PNF & Cuticle as Rx of Ch Paronychia

Focal nail fold biopsy

Focal pathology in the nail fold can be excised by a V-shaped incision into the nail fold

The excision is through the entire thickness of the nail fold, but should not penetrate underlying nail

Relaxing incisions are made at one or both of the lateral margins of the PNF

Wounds in the midline of the nail fold can leave some scarring, but the nail plate is usually unaffected.

Postoperative care

Keep the digit elevated at least at waist

height whenever possible

Sleep with a pillow under the hand or foot

that is treated today to decrease pain

Keep pressure off the biopsy site for at

least the first two days

If your procedure is performed on a toe,

then wear loose fitting shoes

Postoperative care

Keep the wound covered with thin layer of

antibiotic. This keeps air, water and other

irritants off of it and helps it heal faster

Proper dressing can reduce throbbing pain

& Complications

NSAIDs

Nail Biopsy

Complications:- Pain,Bleeding,Necrosis of wound edges,- Trauma to Nail Matrix causes Split nail,Thin

nails & Onycholysis- Pyogenic granuloma,Reflex sympathetic

dystrophy,- Deep infections such as

Osteomyelitis,Septic arthritis

Nail Biopsy

Suturing:- Biopsies with a diametre < 3 mm – not

require - PNF/LNF: Absorbable suture( Vicryl 4-0 for

toes, 5-0 for for fingers )- Nail Matrix : Absorbable suture ( Vicryl 6-

0 )- Nail Bed: Absorbable suture ( Vicryl 5-0 )

Nail BiopsyAdvantages:Never scarring,Easy ProcedureUseful in Isolated nail manifestaionsGives a definitive diagnosis of

onychomycosisMost useful in longitudinal melanonychia &

suspected malignant melanomaTherapeutic benefit in glomus tumour

Nail Biopsy

Disadvantages:

Cases where skin biopsy easily taken

Difficult in patient with DM,PVD

Lack of dermatopathologists

Cases in which nail pathology is likely

to be nonspecific

Lack of well defined histopathological

criteria for some nail diseases

Nail PlateNail bed epithelium

N. Matrix Hyponychium N. Bed dermis

Normal Nail unit HP showing nail matrix area

The nail plate arising over nail matrix area

The characteristic absence of granular layer of nail matrix

Nail Plate biopsy with adherent nail plate epithelium showing evidence of subungual wart

Marked papillomatosis of nail bed epithelium

Onychomycosis

Fungal Pseudohyphae seen in a nail plate biopsy

Nail clippings show septate hyphal elements proven to be Trichophyton sp with in nail plate keratin

90 % Toe nail infections with Trichophyton,Microsporum,Epidermophyton sp

PAS staining most sensitive test

Stain reveals fungal organisms located in lower stratum corneum

Distal subungual Onychomycosis is MC form,caused by T.rubrum

It invades hyponychium & LNF finally yellow,onycholysis,sub ungual hyperkeratosis

T.mentagrophytes identified in superficial white OM,located in superficial nail plate

Onychomycosis

Psoriasis

Nail unit biopsy showing

Parakeratosis Hypergranulosis Parakeratotic abscess Serum crusting

Psoriasis

Spongitic Pustule seen in Epidermis Absence of Granular layer,Acanthosis of Epidermis,Vascular Changes

Lichen Planus

Basal layer dissolution & band like infiltrate in epidermis can be seen

Hyperkeratosis & Superficial Lymphocytic infiltrate

Band like superficial lymphocytic infiltrate along with vacuolar degenration

Lichen Planus

Melanonychia

Pigment laden cells in dermis & Epidermal pigmentation – Melanocytes activation

Nail clippings show Budding yeasts

Candida

Scabies of Nail

Sarcoptes scabiei present in distal subungual hyperkeratotic debris found in hyponychium

Cause of persistent epidemics of scabies

Norwegian scabies severe involvement of nail folds

Scrapings of distal hyponychium- showing organism – Sarcoptes Scabiei

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YOU

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nail biopsy

Health & Medicine