Treatment of Digital Melanonychia with Atypia

Background: Melanonychia of the digit is uncommon in the Caucasian population and is concerning because of potential malignant transformation. Several histologic changes occur prior to malignant transformation, including melanocytic atypia. The aim of this study was to evaluate patients with melanonychia with melanocytic hyperplasia and determine the risk factors for malignant transformation. Methods: We retrospectively reviewed records for patients above the age of 18 years that underwent biopsy for melanonychia. We identified 22 patients with melanocytic hyperplasia with a median age of 61 years (IQR 44-71). A bivariate analysis was performed to evaluate if the degree of atypia was associated with malignant transformation and if treatment choices by surgeons based on melanocytic atypia. Results: Following biopsy, patients were followed for a median of 41.0 months (IQR 4.8-100.6). Melanocytic atypia was present in 9 patients of which three transformed into a malignancy; two became a melanoma in situ and one became an acral lentiginous melanoma. Moderate-severe and severe melanocytic atypia was associated with malignant transformation. After initial biopsy 14 patients were monitored (11 without atypia and 3 with atypia). One patient with slight atypia, two patients with moderate-severe atypia and two patients with severe atypia underwent additional treatment. Patients with melanocytic hyperplasia without atypia were monitored more often (78.6% versus 21.4%). Conclusion: Melanonychia presents a challenge to the hand surgeon, as some patients may be monitored and some should undergo additional resection. Patients with moderate/severe melanocytic atypia following biopsy should undergo resection and those with mild/slight atypia can most often be monitored clinically. Financial Disclosure Statement: Dr. Eberlin, Dr. Jupiter, Dr. Lans and Dr. van Leeuwen have nothing to disclose. No funding was received for this article. Ethical review committee statement: see attached letter Corresponding Author: Kyle R. Eberlin, MD, Division of Plastic Surgery, Massachusetts General Hospital, Wang 435, 15 Parkman Street, Boston, MA 02114, E-mail: keberlin@mgh.harvard.edu, P: 617-643-4902 F: 617-726-8327 ©2018American Society of Plastic Surgeons

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