Splinter haemorrhage

Author(s): Dr Alice Manley, Core Medical Trainee, Southmead Hospital, North Bristol Trust, United Kingdom. DermNet NZ Editor in Chief: A/Prof. Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. February 2019.


What is a splinter haemorrhage?

A splinter haemorrhage is a longitudinal, red-brown haemorrhage under a nail and looks like a wood splinter. Seen end-on, the haemorrhage is in the lower part of the nail plate or underneath it.

Splinter haemorrhages

Who gets splinter haemorrhages?

Splinter haemorrhages can occur at any age; however, they are more common in older people [1,2].

  • In healthy individuals, splinter haemorrhages occur more frequently in men than women.
  • Splinter haemorrhages are more frequent in dark-skinned people than in light-skinned people.
  • The characteristics of patients who develop splinter haemorrhages relate to their underlying cause.

What causes splinter haemorrhages?

The most common cause of a splinter haemorrhage is trauma, including the application of an acrylic nail [3]. 
The longitudinal nature of splinter haemorrhages is explained by the orientation of the capillaries in the nail bed.

Infection

Splinter haemorrhages are present in 15–33% of patients with infective endocarditis in association with Osler nodes and Janeway lesions [3]. They may be due to septic emboli in the small vessels of the nail bed and the increased fragility of the vessel walls in sepsis [2,3].

Other infective causes include:

Skin disease

Splinter haemorrhages are common signs of psoriatic nail disease and nail disease due to lichen planus [3]. They can also be associated with a tumour.

Splinter haemorrhages due to a skin disease

Systemic diseases

Splinter haemorrhages may be due to microemboli or injury to vessel walls associated with vasculitis, including systemic diseases such as [3]:

Splinter haemorrhages are observed in patients with chronic kidney disease on haemodialysis or post-renal transplant, and may be explained by abnormal coagulation [3].

Drugs

Medications associated with splinter haemorrhages include [3]:

What are the clinical features of splinter haemorrhages?

Splinter haemorrhages present as longitudinal 1–3 mm red lines under the nail plate [2,3].

  • They can be single or multiple.
  • They may be asymptomatic or tender.
  • The red line moves distally with time (weeks to months).
  • Haemorrhages under the distal third of the nail plate are frequent and are usually a result of trauma such as a sports injury. They may be associated with subungual haematoma and nail splitting.
  • Proximal haemorrhages, especially affecting multiple fingernails, are more likely due to a systemic disease, especially in women.

What are the complications of splinter haemorrhages?

There are no complications of splinter haemorrhages themselves; complications arise as a consequence of the underlying disease process.

How is a splinter haemorrhage diagnosed?

A careful history and physical examination are required to determine the underlying cause.

The diagnosis of splinter haemorrhages is made clinically or with the aid of dermatoscopy [1].

Dermoscopy of splinter haemorrhages

What is the treatment for a splinter haemorrhage?

There is no specific treatment for a splinter haemorrhage.

Any treatment is targeted at an underlying systemic condition or at discontinuing a causative drug.

What is the outcome for a splinter haemorrhage?

If caused by trauma, a splinter haemorrhage grows out and disappears. Haemorrhages may continue to recur if the underlying cause remains.

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Related information

 

References

  1. Tosti A, Piraccini BM. Nail disorders. Dermatology, 71, 1203–19
  2. Baran R, Dawber RPR. Diseases of the nails and their management, 4th edn. Chichester: John Wiley & Sons, 2012.
  3. Haber R, Khoury R, Kechichian E, Tomb R. Splinter haemorrhages of the nails: a systematic review of clinical features and associated conditions. Int J Dermatol 2016; 55: 1304–10. PubMed

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