Foreign Body, Trauma, Nail, Case, Teledermatology



  1. Chung, Michael Y.
  2. Macknet, Kenneth D.
  3. Jacob, Sharon E.


ABSTRACT: Teledermatology is a term to describe the provision of dermatologic medical services through telecommunication technology. This is a case of blue-gray linear discoloration under the nail of the little finger.


Article Content

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.




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.



Minimally satisfactory with suggestions for improvement. Only one image is provided. Five images of a subject lesion are preferred, including at least one dermatoscopy.



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).

Figure 1 - Click to enlarge in new windowFIGURE 1. The right little finger with a midway longitudinal streak under the nail bed.


Lesion A Findings

The presented lesion and history are most consistent with a subungual foreign body possibly composed of graphite from mechanical pencil lead.



Recommend patient to present to urgent care or dermatology clinic for subungual exploratory extraction and partial nail avulsion if necessary (Chan & Salam, 2003).



Two-week follow-up to evaluate nail growth and for inflammation.



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.




Chan C., & Salam G. A. (2003). Splinter removal. American Family Physician, 67(12), 2557-2562. [Context Link]


DerSarkissian C. (2017). Splinters treatment. Retrieved July 15, 2019, from[Context Link]


Lee C. K., Ahmad T. S., & Abdullah B. (2008). Splinter removal with the aid of ultrasonography: A case report. Malaysian Orthopaedic Journal, 2(2), 47-49. [Context Link]


Mercado L. N. S., & Hayre C. M. (2018). The detection of wooden foreign bodies: An experimental study comparing direct digital radiography (DDR) and ultrasonography. Radiography, 24(4), 340-344. [Context Link]


Roman M., & Jacob S. E. (2015). Teledermatology: Virtual access to quality dermatology care and beyond. Journal of the Dermatology Nurses' Association, 6(6), 285-287. [Context Link]


Schmitt B. D. (2014). Slivers or splinters (foreign body in skin). Retrieved July 15, 2019, from[Context Link]


Winland-Brown J. E., & Allen S. (2010). Diagnosis and management of foreign bodies in the skin. Advances in Skin & Wound Care, 23(10), 471-476. [Context Link]


1The standardized teledermatology reader report format is available for authors on the journal's website ( and on the submissions website online at [Context Link]