Q: I recently noticed a light brown streak on a few of my fingernails. I was wondering if you can give me advice on how serious this is. Like anyone else, I researched it and it all leads to cancer. I would really appreciate your thoughts.

A: You are concerned about nail melanoma. Melanoma is a type of cancer that most people tend to associate with the skin; however, melanoma can arise in the nail as well. Melanoma occurs when the pigment-producing cells in the nail (melanocytes) begin to grow in an uncontrolled fashion. Although melanoma in the nail often appears as a single pigmented brown or black band, most brown or black pigmented bands in the nail are benign or non-worrisome. Other causes of single brown pigmented bands in the nail are either benign moles or simply the pigment cells “waking up” and producing pigment much like when a new freckle appears in the skin. Unfortunately, early melanomas are very difficult to distinguish from benign pigmented bands and that is why it is imperative to see a dermatologist for a thorough exam and consultation when it is unclear what the diagnosis is.

Pigmented bands in the nail are common and usually normal, especially in people with darker complexions. This is because the nail, similar to the skin, has pigment-producing melanocytes. These cells mostly reside in the half moon region of the nail (the distal matrix). Therefore, people with a lot of melanocytes in their skin tend to have a higher number of these pigment-producing cells in their nails and will often have multiple pigmented bands in the nails, which are usually not a concern. When stimulated, these cells begin to produce pigment, appearing as a brown, lengthwise band in the nail.

So what stimulates these cells? Trauma to the matrix region is a definite stimulator. Any trauma to the cuticle area can result in stimulation of these pigment-producing cells because the cuticle lies directly over the area where the melanocytes reside. Aggressive and repetitive cuticle pushing, cutting, picking, or biting can stimulate these pigment-producing cells to wake up and start making pigment. Even some medications can stimulate the nail’s melanocytes.

If caught early, nail melanoma is curable. Unfortunately, nail melanoma tends to be diagnosed late. If you suspect that you may have a melanoma or are not sure what is going on with your nail, see a board-certified dermatologist in your area.

Q: My nail got split when I was 10 years old. It seems dead and grows with some space between the nail. What could this condition be?

A: It sounds like you may have permanently damaged part of your nail matrix (the structure that turns into the nail). Unfortunately, the nail matrix is a very delicate piece of tissue and it doesn’t repair itself well. Permanent damage to the matrix can result in permanent nail dystrophy (nail abnormalities) such as the lifting (onycholysis) that you describe.

Q: My nail is so rough. When I checked with a doctor he said that it’s a pitting problem. So now I take a vitamin for nails. Please tell me which to use?

A: Pitted nails can be the sign of several inflammatory disorders including psoriasis and alopecia areata. I would recommend seeing a board-certified dermatologist to make sure that you are being properly diagnosed.

Q: I am on Tamoxifen after having breast cancer and I understand that the treatment for onycholysis requires a drug that doesn’t interact with it. Are you able to confirm that?

A: Many of the Taxane chemotherapeutics cause onycholysis. The good news is that once the chemotherapy is stopped, the nail usually readheres over time. Onycholysis is one of the most common nail disorders that I treat in my practice. It is very rare that I have to use an oral treatment. You should see very good results with a topical anti-yeast medication as well as adhering to a strict irritant-avoidance regimen. This means keeping your nails dry and avoiding nail cosmetics during the treatment period.  

Q: For as long as I can remember I have had a horrible habit of biting my nails, and as I get older it has gotten a lot worse. I am very ashamed of my nails and would like some help on getting healthy strong nails.

A: Onychophagia (chronic nail biting) can have many consequences. Biting can, over time, result in nail shape change, such as a shorter, wider nail, as well as white patches (punctate leuknonychia) or brown/black stripes (melanonychia striata) from stimulation of the melanin-producing cells in the matrix. Additionally, if you are biting near the cuticle, you can create a chronic paronychia. This is due to the cuticle barrier becoming compromised and yeast entering the nail unit. If left untreated, the nail will eventually grow in with surface irregularities.

The first step to stopping nail biting is to develop self-awareness and become psychologically attuned to the habit. Once you have a sense of “high risk” biting times or triggers, it is key to have something handy that will help you to divert the behavior. There are a lot of new hand-held “fidget” devices such as the fidget cube and spinner that have helped a lot of my patients. Gel manicures can also be an incredible tool to help nail biters to “bite the habit” because they create an armor-like protective barrier. Often if you have spent the time and money to have a manicure, it is a motivation not to bite. If you can resist biting for 12 weeks, it is likely that you will be successful at stopping. If breaking the habit is proving challenging, it is often helpful to see a cognitive behavioral therapist.

To read more Q&As from Dr. Stern, go to www.nailsmag.com/danasternQA.

Dermatologists treat skin, hair, and nails. I am a board-certified dermatologist and I specialize in the treatment of nail disorders including inflammatory diseases of the nail, cosmetic issues related to the nail, cancers of the nail, sports-related nail injuries, and nail infections.

Read previous “day in the life” articles by Dr. Stern at www.nailsmag.com/danastern.

You can contact Dr. Stern with your questions via Facebook (www.facebook.com/danasternmd) or Twitter (@DrDanaStern). Visit her at www.drdanastern.com and www.drdanabeauty.com.