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Nail Biopsy

At Livingstone Dermatology, we understand that your skin is a reflection of your health and well-being. We are committed to the latest advancements in dermatological science, and dedicated to providing you with quality care.

What is a Nail Biopsy?

A nail biopsy is a medical procedure that involves taking a small tissue sample from specific parts of the nail for diagnostic purposes. This can be done by dermatologists to investigate certain abnormalities in the nail or its surrounding structures, such as deformities or lesions [1].

This is performed when there are abnormalities in the nail that cannot be diagnosed through a typical clinical exam or non-invasive tests.

Are Nail Biopsies always performed to diagnose nail issues?

No, a nail biopsy is usually recommended when other less invasive methods, such as a microscopy or culture, do not suffice in providing a diagnosis. It can also be performed if you experience progressive or worsening changes in your nails, as this could suggest a more serious underlying condition.

What is a Nail Biopsy for?

Nail biopsies are done to diagnose or rule out certain conditions of the nail or around the nail that cannot be diagnosed from other parts such as the skin, common conditions include:

Pigmented lesions — Discolouration or dark streaks of the nail (melanonychia) can be examined by a nail biopsy to rule out subungual melanoma (cancer of the nail pigment unit).
Infections — Nail biopsies can diagnose fungal or bacterial infections of the nail.
Tumours — Benign and malignant tumours of the nail are usually diagnosed via a nail biopsy. This is common to determine the nature of the growth before proceeding with the next course of action.
Inflammatory or autoimmune disorders — Conditions such as psoriasis, lichen planus or lupus that appear on the nails are indicated for nail biopsies either to rule out or diagnose the condition.
Trauma-related structural abnormalities — Underlying damage or structural abnormalities to the nail that resemble other conditions can be ruled out with a nail biopsy.
Unknown nail dystrophy — Persistent changes in nail shape, texture or thickness with an unknown cause require further investigation to determine its cause.

Common conditions diagnosed via Nail Biopsy

Nail biopsies are performed when the indicated lesion is isolated in the nail, and cannot be diagnosed on other parts. Common conditions diagnosed via a nail biopsy include:

Melanonychia [2] – Melanonychia refers to dark discoloration of the nails, which can be caused by nail melanoma, an underlying condition, or nutritional deficiencies.
Melanoma – Melanoma lesion of the skin concealed under the nail.
Onychomycosis – Fungal infection caused by Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum. Other pathogens such as Candida albicans, Fusarium, Aspergillus, and Acremonium can also cause this infection.
Nail psoriasis – Nail psoriasis is an autoimmune disorder which causes pitting of nails, discoloration, and nail bed separation.
Lichen planus – Lichen planus is an inflammatory condition of the skin and mucous membranes, presentation on nails appears as grooves, scarring, and nail bed separation.
Nail dystrophy – Nail dystrophy refers to abnormal changes to the nails such as colour, texture, and shape. It can be caused by many factors such as infections, injuries, medications, or underlying conditions.
Tumours of the nail – Nail tumours can be benign, such as onychomatricoma (tumour of the nail matrix), glomus tumour, and pyogenic granuloma, or malignant such as squamous cell carcinoma, melanoma, and basal cell carcinoma [3].

A nail biopsy can be recommended by your dermatologist if your nail condition is chronic and keeps returning. It is a helpful diagnostic approach to determine the best course of treatment for your condition. In certain cases, a nail biopsy diagnosis can lead to nail surgery, where your dermatologist will treat the condition.

Types of Nail Biopsies

Depending on the location and type of lesion, your dermatologist may choose to perform either of the following:

Nail plate biopsy – Biopsy is taken from the nail itself, this procedure is the least invasive out of all the types of nail biopsies.
Nail bed biopsy – Biopsy is taken from the nail bed, the region where the nail rests on the finger. This is the most common type of nail biopsy performed and may require avulsing or lifting the nail plate to access the nail bed underneath.
Nail matrix biopsy – Biopsy is taken from the nail matrix. The nail matrix consists of specialised cells responsible for growing new fingernails or toenails. This procedure may be of higher risks than other biopsies.
Nail fold biopsy – Biopsy is taken from the nail fold, the region where your skin meets and borders the nails. This can be either proximal nail fold or lateral nail fold.

Aside from the location of the biopsy, the type of biopsy also differs in terms of procedure. Common nail biopsy procedures include [4]:

Excision biopsy – The dermatologist uses a scalpel to cut out a portion of the tissue
Punch biopsy – A punch biopsy involves using a circular tool to obtain a section of tissue.
Shave or excision biopsy – This procedure involves removing a thin layer of tissue from the surface using a scalpel.

The type of nail biopsy you will need will depend on the dermatologist’s initial evaluation and assessment of your condition. The dermatologist will also go over risk assessment with you before performing a biopsy. Consult with our dermatologist if you have any doubts or concerns.

Are there any risks associated with nail biopsies?

Nail biopsies may involve invasive procedures, hence risks and side effects are present and should be well understood before undergoing a procedure. Risks associated vary with the type and location of procedure and technique. Less invasive techniques such as nail plate biopsies will come with lower risks than nail bed or nail matrix biopsies. Common complications of the procedure include [4]:

Bleeding
Infections
Scarring
Reduction of nail width
Misaligned regrowth of the nail
Delayed healing

That said, these complications are rare, and having the nail biopsy procedure performed by a trained dermatologist significantly minimises these risks. It also helps to follow post-procedure care instructions provided by your doctor to further reduce any likelihood of complications.

What can I expect from a nail biopsy procedure?

The process of a nail biopsy typically goes as follows:

Consultation
Before any procedure is done, a consultation is necessary for the dermatologist to assess and examine your nail. They will recommend a nail biopsy if needed.
Preparation
Before the procedure, your nail and the surrounding area will be cleaned and a local anaesthesia will be administered to numb the area, and ease any pain or discomfort. A tourniquet may be applied to the digit to reduce bleeding.
Biopsy
A nail biopsy sample will be carefully collected. This tissue sample will then be used for further examination and diagnosis:
— The nail plate — for external abnormalities on the surface of the nail.
— The nail bed or matrix — for deeper or concealed lesions, or growth-related conditions.
— Areas surrounding the nail — surrounding areas, such as the nail folds or hyponychium.
The time taken for the procedure depends on the type of biopsy, some procedures are relatively quick and can be completed in 15 minutes to half an hour.
Results
Once the biopsy results are available, your dermatologist will provide a comprehensive diagnosis followed by the recommended course of treatment.
Treatment
Treatment of your nail condition will be given by your dermatologist to address the cause of the condition. You will also be given aftercare instructions to ensure a smooth recovery.

Aftercare notes for your Nail Biopsy

Generally, after your procedure, your doctor will advise you on the following aftercare practices:

Wound care — It is important to keep the biopsy site clean and dry for the first 24 hours after your procedure. Remember to apply any creams or dressings prescribed by your doctor.
Dressing — Change the dressing daily or as often as advised, and use sterile bandages to prevent infection.
Pain management — Mild pain is normal, and can be alleviated with the prescribed pain medication.
Activity restrictions — Avoid strenuous activities that may put pressure on the affected nail. It also helps to wear open-toed shoes to prevent irritation.
Infection prevention — Try to be observant, and look out for signs of infection, like redness, warmth or pus. Should you experience this, contact your dermatologist immediately.

After this, you will have a follow-up session to monitor your healing and for your doctor to go through your biopsy results with you.

How long will it take my nail to heal after a biopsy?

Generally, how long it takes to heal from a nail biopsy largely depends on the extent of the procedure and the type of biopsy performed. Generally, here’s what to expect:

The skin and soft tissues around your nail will heal between 2 – 6 weeks.
Nail plate regrowth:
— Partial nail removal — the nail may regrow within a few weeks as the wound heals.
— Entire nail removal — Fingernails may take 4-6 months to fully regrow, while toenails take 9-12 months.

When should I visit a Dermatologist?

You should consult a dermatologist if you notice abnormal or concerning changes on your nails, such as:

Changes in colour – Dark streak along the nail, greenish black colour, yellowing of the nail.
Changes in shape or texture – Nail plate lifting from the nail bed, pitted nails, deep grooves across the nail.
Unusual growths — Any new or unexplained growths under or around the nail.
Redness, swelling, or pain — Unexplained redness, swelling or pain around the nail could signal an infection or inflammatory condition that may need treatment.

Certain changes in the nail can be caused by injury, chemotherapy, or stress. If these are unlikely to have occurred recently, seeking professional medical help is highly recommended.

Just like hair and skin, nails can reflect our health and well-being. When something seems out of the ordinary or starts to cause discomfort, a consultation to a dermatologist can be helpful in identifying and managing your concerns.

Here at Livingstone Dermatology, we are dedicated to providing personalised, expert care for every aspect of your skin health, including your nails. If you’re experiencing persistent nail concerns or unusual changes, schedule a consultation with us today for a comprehensive diagnosis and treatment plan tailored to your needs.

Frequently Asked Questions

Does a nail biopsy hurt?

Local anaesthesia is usually administered to reduce pain and discomfort during the procedure. It is generally well-tolerated, and you may only experience some pressure, but no sharp pain.

Will the nail grow back normally after a nail biopsy?

Yes, a nail biopsy that does not damage the nail matrix should allow the nail to grow back normally. However, there are still risks of regrowth defects.

How long does the procedure take?

Depending on the site of biopsy, the procedure may take anywhere from 15 minutes to several hours. For example, biopsy of the nail matrix or nail bed that requires anaesthesia and specialised tools and techniques will take longer than biopsy of the nail plate.

What can I not do after a nail biopsy?

The dermatologist will advise on post-operative care after your nail biopsy, this may vary on a case by case basis. General care of the digit may include changing bandages, keeping it dry, and elevating the digit for the first 48 hours after surgery. Strenuous and risky activities should also be avoided to reduce risks of injury and pain.

References

Rich P. Nail biopsy: indications and methods. Dermatol Surg. 2001 Mar;27(3):229-34. PMID: 11277887.
Singal A, Bisherwal K. Melanonychia: Etiology, Diagnosis, and Treatment. Indian Dermatol Online J. 2020 Jan 13;11(1):1-11. doi: 10.4103/idoj.IDOJ_167_19. PMID: 32055501; PMCID: PMC7001389.
Richert, B., Lecerf, P., Caucanas, M., & André, J. (2013). Nail tumors. Clinics in Dermatology, 31(5), 602–617.
Grover C, Bansal S. Nail Biopsy: A User’s Manual. Indian Dermatol Online J. 2018 Jan-Feb;9(1):3-15. doi: 10.4103/idoj.IDOJ_268_17. PMID: 29441291; PMCID: PMC5803938.

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