Nail biopsy

1. D R . Y U G A N D A R
NAIL BIOPSY

2. Nail Biopsy
Two Primary reasons to perform biopsy
- Confirm diagnosis of disease
- Remove neoplasm or correct deformity (d/t pain )

3. 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

4. Nail Biopsy
Indications:
- Differentiate b/w inflammatory & infective
disorders affecting nail unit
- To establish diagnosis of one or 20- nail dystrophy

5. Nail Biopsy
- To establish cause of longitudinal pigmented streaks
- Differentiate Subungual hematoma & Malignat
melanoma

6. Nail Biopsy
Indications:
- Differentiate benign & malignant tumours
- To identify the cause of pain ( eg Glomus tumour )
 Contraindications:
- Severe uncontrolled diabete
- Severe Peripheral vascular diseases

7. Nail Biopsy
Biopsies of nail :
- Nail Plate
- Nail bed
- Nail Matrix
- Nail fold
- Nail unit Biopsy ( Combined Biopsy of LNF,Lateral
Nail Matrix & PNF )

8. Different types of nail biopsy

9. Site & technique of nail biopsy for common nail
disorders

10. Site & technique of nail biopsy for common nail
disorders

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

12. 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

13. 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,Previous
diagnostic tests,

14. Nail Biopsy
- Cutaneous H/O-
H/O Nail Condition
(Duration,Progression,Exposure,Trauma)
Previous Malignancies,Fungal,Bacterial
infections,Psoriasis,Lichen planus
Occupation,Hobbies

15. Nail Biopsy
Examination:
- All 20 nails,good lighting & magnification
- Mucous membranes,hair & Scalp
- Perpheral pulses

16. Nail Biopsy
Laboratory tests:
- X-ray,Mycology,Microbiology

17. 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

18. 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

19. 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

20. 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

21. Nail Biopsy
- Penrose drains
- English nail splitter,clippers
- Disposable biopsy punches

22. Nail Biopsy Instruments
Double action nail nipper & Freer Eleavator on left side of tray

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

24. Freer Eleavator – Proximal
nail Plate avulsion
English Nail splitter used to
divide nail plate prior nail
avulsion
Nail Biopsy Instruments

25. 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

26. Nail Biopsy
 Lidocaine with adreanaline combination for digital
anesthesia still controversy

27. Nail Biopsy
Digital Anesthesia:
Distal nail blocks
1. Distal digital block
2. Distal anesthesia through PNF
3. Distal anesthesia through hyponychium

28. Nail Biopsy
 Proximal digital blocks
 Transthecal digital blocks
 Regional blocks

29. 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

30. 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 )

31. Nail Biopsy
Different Digital sites of injection for Ring block

32. Site of Lidocaine injections for wing & digital block

33. 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

34. Advantages Disadvantages
 Immediate effect < 1
min
 Low risk of
neurovascular
compromise
 Induces compression
hemostasis
 Local injection
 Relatively painful
 May cause
inadequate coverage
& swelling of surgical
field in large
surgeries
Nail Biopsy
Distal Digital Block

35. Distal Digital Block

36. Median Distal Block

37. 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

38. Dorsal View Ventral View
Proximal Digital block

39. 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

40. Tourniquet
Sterile Glove used as Tourniquet

41. 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

42. Penrose drain
Sterile glove with artery
forceps
Tourniquet

43. Patterns of Nail Biopsy
Nail Avulsion
Nail bed biopsy
Matrix biopsy
1. Lateral Longitudinal nail biopsy
2. Transverse matrix biopsy
3.Matrix shave

44. 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

45. 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

46. 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.

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

48. Nail Avulsion
Freer Eleavator inserted under
nail plate
Loosened nail plate is grabed
with hemostat & removed

49. Nail Avulsion
 Digital block has been
performed

50. Nail Avulsion
 Apply rubber band

51. Nail Avulsion
 Release eponychium and
lateral side

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

53. Nail Avulsion
 Grasp as much nailplate
into needledriver or
hemostat

54. Nail Avulsion
 Continue cutting
undernath cuticle

55. Nail Avulsion
 Remove nailplate by
gentle traction and
rotating outward

56. Distal Nail Avulsion Proximal Nail Avulsion
Nail Avulsion

57. 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

58. Removal of Nail Plate

60. 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

61. 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

62. Nail Bed Biopsy
 It may reattach or at least provide a natural dressing
during the early healing phase.
 No Scarring from biopsy

63. Nail Bed Biopsy
 Suspected nail bed
glomus tumour

64. Nail Bed Biopsy
 Subungual glomus
tumour seen as a bluish
mass after nail plate
avulsion

65. Nail Bed Biopsy
 Excision of tumour done
 Nail bed incisons are
oriented longitudinally

66. Nail Bed Biopsy
 > 3 mm size needs to be
sutured

67. Punch Biopsy Fusiform Biopsy
Nail Bed Biopsy

68. 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

69. 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

70. 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

71. Nail Matrix Biopsy

72. 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

73. 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

74. 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

75. Lateral Longitudinal Nail biopsy
 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

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

77. Lateral Longitudinal Nail biopsy
Area to be excised
outlined,The
incision is linear
medially & curved
laterally

78. Lateral Longitudinal Nail biopsy
The incision is
carried down to
periosteum &
tissue is lifted
up with sharp
scissors

79. Lateral Longitudinal Nail biopsy
The separated specimen
forhistopathologic examination

80. Lateral Longitudinal Nail biopsy
The defect is sutured back

81. Lateral Longitudinal Nail biopsy
 Lateral portions of nail
unit excised enbloc
 Includes
Hyponychium,nail
plate,nail matrix,nail bed
& PNF

82. 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

83. Transverse Matrix biopsy
 A thin ellipse is taken from the distal matrix with the
distal margin of the excision matching the shape of
the lunula

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

85. 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 specimen
 The nail plate is replaced to prevent contact
between the wound and ventral aspect of the nail
fold
 suture repair is not required.

86. Matrix shave or tangential biopsy

87. 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.

88. Proximal nail fold biopsy
Method of removing small lesion from the PNF

89. 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.

90. 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.

91. 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

92. Crescentic nail fold biopsy
 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

93. Crescentic nail fold biopsy
Crescentic shave of distal PNF & Cuticle as Rx of Ch Paronychia

94. 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.

95. 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

96. 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

97. 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

98. 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 )

99. Nail Biopsy
Advantages:
 Never scarring,Easy Procedure
 Useful in Isolated nail manifestaions
 Gives a definitive diagnosis of onychomycosis
 Most useful in longitudinal melanonychia &
suspected malignant melanoma
 Therapeutic benefit in glomus tumour

100. 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

102. Nail Plate
Nail bed
epithelium
N. Matrix
Hyponychium N. Bed dermis

103. Nail Plate
Nail bed
epithelium
N. Matrix
Hyponychium N. Bed dermis

104. 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

105. Nail Plate biopsy with adherent nail plate epithelium
showing evidence of subungual wart
Marked papillomatosis of nail bed epithelium

106. Onychomycosis
Fungal Pseudohyphae seen in a nail plate biopsy

107. Nail clippings show septate hyphal
elements proven to be Trichophyton
sp with in nail plate keratin
 90 % Toe nail infections with
Trichophyton,Microsporum,Epi
dermophyton 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

108. Psoriasis
Nail unit biopsy showing
 Parakeratosis
 Hypergranulosis
 Parakeratotic abscess
 Serum crusting

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

110. Lichen Planus
Basal layer dissolution & band like infiltrate in epidermis can be seen

111. Hyperkeratosis & Superficial
Lymphocytic infiltrate
Band like superficial lymphocytic
infiltrate along with vacuolar
degenration
Lichen Planus

112. Melanonychia
Pigment laden cells in dermis & Epidermal
pigmentation – Melanocytes activation

113. Nail clippings show Budding
yeasts
Candida

114. 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

115. THANK
YOU
Have a nice day