Splinter hemorrhages



Subungual hemorrhages are small, thin red-brown lines under the nails and run in the direction of nail growth.

Caused by microscopic blood clots in the capillaries under the fingernails, which, in turn, can be caused by septic emboli from infected heart valves in bacterial endocarditis.


Splinter hemorrhages typically appear as reddish brown to black small, thin, longitudinal streaks, usually 1 to 3 mm in length, in the nail bed under the nail plate.


Splinter hemorrhages are  longitudinal lines arising  from damaged capillaries in the longitudinally oriented epidermal-dermal ridges in the nail bed, with resultant leakage of blood from the capillaries.


Splinter hemorrhages are usually asymptomatic.


They do not blanch on pressure.


The process is more common in males than in females and in African Americans than in Whites.


Mostly on the fingernails rather than on the toenails.


Usually confined to a single, but multiple digit involvement is more consistent with a systemic causation.


Most  common causes: trauma, occupation-related or sport-related, but should also include, onychomycosis, 

followed by nail psoriasis.


Many associated causes include: 


infectious diseases-septicemia, subacute bacterial endocarditis, fungal endocarditis, onychomycosis, meningococcemia, trichinosis, histoplasmosis; tick bite, leukemia, thrombocytopenia purpura, cutaneous T-cell lymphoma, nail tumors, chronic dermatitis-lichen planus, eczema, Darier disease, connective tissue diseases;systemic lupus erythematosus, rheumatoid arthritis, antiphospholipid syndrome, Raynaud disease, hypereosinophilic vasculitis, medications; warfarin, aspirin, sorafenib, sunitinib, cabozantinib, zolpidem, tetracycline, terbinafine; chronic kidney disease, endocrine diseases-diabetes, thyrotoxicosis, hypoparathyroidism; gastrointestinal tract diseases-peptic ulcer disease, cirrhosis, hemochromatosis, internal malignancy, scurvy, hypertension, exposure to high altitude, radial artery puncture, local radiation, sarcoidosis, tuberous sclerosis complex, Langerhans cell histiocytosis, hereditary hemorrhagic telangiectasia, Behcet disease, granulomatosis with polyangiitis, and thromboangiitis obliterans (Buerger disease).


Idiopathic atraumatic splinter hemorrhages can occur in healthy individuals


Idiopathic splinter hemorrhages and those as a result of trauma are more commonly located in the distal third of the nail.


Splinter hemorrhages as a result of systemic diseases are usually in a proximal location. 


Bacterial endocarditis associated splinter hemorrhages typically appear in the mid-portion of the nail.


The diagnosis is mainly clinical.


In general, splinter hemorrhages move distally as the nail grows, as the extravasated blood is attached  to the nail plate.


Occasionally, splinter hemorrhages remain stationary if the blood attaches to the nail bed rather than the nail plate.





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