In the store-and-forward teledermatology modality, there is an electronic transfer of a patient's medical information, which includes both the history and visual data obtained in one location, to a provider who is in another location (Roman & Jacob, 2015). The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.
TELEDERMATOLOGY READER REPORT1
History
Chief Complaint: Presenting for recommendations.
History of Present Illness
A 48-year-old college professor presents for evaluation of a throbbing right little finger with a blue-gray hue under the nail bed after sorting her desk drawer containing papers and mechanical pencils. Prior treatment: none. Her primary symptom: constant, sharp, and throbbing pain of finger. Prior biopsy: none. History of skin cancer/growth: unknown. Other significant laboratory/study findings: none.
IMAGE QUALITY ASSESSMENT
Minimally satisfactory with suggestions for improvement. Only one image is provided. Five images of a subject lesion are preferred, including at least one dermatoscopy.
TELEDERMATOLOGY IMAGING READER REPORT
One image was provided that showed a solitary, midway blue-gray longitudinal streak underneath the medial aspect of the right little finger nail bed (Figure 1).
INTERPRETATION OF IMAGES
Lesion A Findings
The presented lesion and history are most consistent with a subungual foreign body possibly composed of graphite from mechanical pencil lead.
RECOMMENDATIONS
Recommend patient to present to urgent care or dermatology clinic for subungual exploratory extraction and partial nail avulsion if necessary (Chan & Salam, 2003).
RECOMMENDED FOLLOW-UP
Two-week follow-up to evaluate nail growth and for inflammation.
CLINICAL PEARL
Splinters are common in children and adults, most commonly presenting as a foreign body embedded in the epidermis or subcutaneous tissue. Various common foreign bodies include wood, glass, metal, and gravel (Winland-Brown & Allen, 2010). Although usually easily removable at home, some splinters can be difficult to remove and, if retained, cause local inflammation that can lead to infection with abscess or granuloma formation (Lee et al., 2008). Reactive objects such as wood, thorns, spines, and other vegetative foreign bodies are more prone to cause these adverse reactions, whereas glass, metals, and plastic are more inert materials that can be removed electively (Chan & Salam, 2003).
Whereas splinters can usually be easily visualized and palpated, others may only be indicated by symptoms including a draining sinus, sudden inflammation, or a poorly healing wound (Winland-Brown & Allen, 2010). If the history indicates the possibility, physicians should investigate for a foreign body in these cases. If needed, imaging modalities have been found to be useful in visualizing foreign bodies (Lee et al., 2008). Ultrasound has been shown to be superior to other imaging modalities at identifying foreign bodies at least 5 mm in length (Mercado & Hayre, 2018).
Splinters may be removed using a "needle and tweezers" (Schmitt, 2014). The authors assert to sterilize the tools and the affected skin with alcohol and then utilize the needle to expose the free end of the splinter, which can then be grasped by the forceps to extract at the angle of entry. With this technique, antibiotic ointment is recommended to prevent infection before bandaging (DerSarkissian, 2017). For embedded splinters under a fingernail that cannot be removed by the technique described above, one reported extraction technique is to create a V-shaped notch in the nail to expose the end of the splinter for forceps extraction (Chan & Salam, 2003). An alternative technique is to partially avulse the nail by shaving the nail overlying the splinter with a No. 15 blade. By using light strokes with the blade in a proximal-to-distal direction, a U-shaped defect can be formed exposing the length of the splinter (Chan & Salam, 2003). The technique used in our outpatient dermatology practice is minimally invasive and does not require incising, vaporizing, or removing the nail plate, which means the technique is efficient, effective, and safe and minimizes healing time.
REFERENCES