Splinter Hemorrhages - Causes, Clinical Features, Diagnosis, and Treatment

What Are Splinter Hemorrhages?

Splinter hemorrhages are small linear subungual hemorrhages that are red when fresh and brown when aged, located at the distal one-third of the nail bed, and classically associated with mitral stenosis (narrowing of the mitral valve orifice). Splinter hemorrhages are also seen in Splinter hemorrhages are also seen in subacute bacterial endocarditis infection (inflammation of the heart’s inner lining). They can occur in all age groups but are most common in older people. In comparison with sex, it is found that men have a higher occurrence rate of splinter hemorrhages than females. Apart from this, splinter hemorrhages are common in individuals with certain underlying systemic conditions.

• Age: Common in older people.

• Sex: Men are more susceptible than females.

• Other: Most common clinical feature in people with systemic conditions.

The splinter hemorrhage healing process usually takes three to four months. The splinter hemorrhages will disappear as the nails grow over time.

What Are the Symptoms of Splinter Hemorrhages?

Splinter hemorrhages are seen as red blood spots (or sometimes black lines or spots), which cause bleeding initially. It appears longitudinal, following the direction of the blood capillaries situated at the distal end of the nail beds. It appears as small, thin blood streaks on nails and can also be present as a single line in a number or multiple. These lines often become black due to tiny clot formation under the nails and appear as black lines or spots (splinter hemorrhage nails). Depending upon the cause, the individual gets pain. For example, in the case of nail injury, splinter hemorrhages exhibit severe pain, but in cases of underlying systemic conditions such as bacterial endocarditis, it is asymptomatic.

• Color: Red.

• Length: 0.04 inches.

• Location: Distal third.

• Number: Either single or multiple.

• Finger distribution: Right thumb and index finger.

• Type: Non-blanchable.

What Are the Causes of Splinter Hemorrhages?

Splinter hemorrhages occur in various conditions; the most common cause is trauma or injury, which also includes acrylic nail application. Splinter hemorrhages follow the orientation of nail bed capillaries because they are longitudinal. It is found that 15 to 30 percent of splinter hemorrhages are seen in association with Osler nodes (tender, purple-pink nodules, with pale center, having an average diameter of 0.04 inches, fund in distal toes and fingers) and Janeway lesions (irregular, erythematous, non-tender, or hemorrhagic macules commonly found on the soles and palm). Splinter hemorrhages are seen in skin diseases like psoriatic nail disease and lichen planus (inflammatory condition of mucous membrane and skin).

Which Systemic Conditions Show Splinter Hemorrhages as a Clinical Feature?

Some of the conditions are as follows:

1. Trauma - It is the most common cause of splinter hemorrhages.

2. Dermal Infections:

• Dermatosis - Skin lesions or irregularities, such as psoriasis (scaly and inflamed skin) and lichen planus (inflammation of mucus membrane and skin).

3. Connective Tissue Disorders And Vasculitis

• Wegener's granulomatosis - Inflammation of the blood vessels.

• Digital vasculitis - damaged blood vessels due to swelling or inflammation.

• Medium vessel vasculitis.

• Systemic Juvenile Idiopathic Arthritis - Persistent joint pain, stiffness, and swelling.

4. Infectious Diseases

• Subacute Bacterial Endocarditis - Infection caused by bacteria entering the bloodstream and damaging the lining of the heart.

• Psittacosis - Disease spread from an infected bird belonging to the parrot family to humans.

• Endarteritis - Inflammation of the inner lining of the arteries.

• Meningococcemia - A bacterial infection of the bloodstream.

5. Renal Diseases

• Hemodialysis - Blood purification process.

• Renal (kidney) transplantation.

6. Drug-induced Splinter Hemorrhages

• Tyrosine-kinase inhibitors (Sunitinib, Sorafenib).

• Ganciclovir.

• Nitrofurantoin.

• Terbinafine.

7. Idiopathic Splinter Hemorrhages

• Elder age.

• High altitude.

• Longitudinal erythronychia - Linear red band on the nail plate that originates at the proximal nail fold, traverses the lunula, and extends to the free edge of the nail plate.

• Idiopathic splinter hemorrhage (playing percussion instruments, household work, sports activities, and certain nail-related habits). Splinter hemorrhages are tiny spots of blood under the nails.

8. Miscellaneous

• Melanoma - Skin cancer.

Splinter hemorrhages due to the injury of blood vessels or microemboli in systemic diseases include vasculitis (inflammation of blood vessels), systemic lupus erythematosus (an autoimmune disease), Raynaud's disease (it causes the body to feel cool and numb in certain conditions), Behcet disease (causes inflammation in blood vessels), and cutaneous vasculitis.

Some of the risk factors of splinter hemorrhages are mentioned below.

• Diabetic patients, particularly type 2 diabetic patients, show symptoms of dark lines in nails due to the increased sugar in blood vessels.

• Individuals with high cholesterol levels have an increased risk of mitral stenosis.

• Vitamin C deficiency.

• Oral contraceptive pill intake.

Is Splinter Hemorrhages a Side Effect of Cancer Treatment?

Drugs used to treat cancer show nail changes, including splinter hemorrhages. Such drugs are

• Doxorubicin.

• Docetaxel.

• Paclitaxel.

• Nab-paclitaxel.

Can Nail Biting Cause Splinter Hemorrhages?

In conditions like onychophagia (nail-biting compulsive behavior), the destruction of the nail plate can cause splinter hemorrhages. Onychophagia is commonly found among children and young adults. Onychophagia can also cause numerous nail changes, including nail dystrophy, partial or total loss of nails, and longitudinal melanonychia. Splinter hemorrhages with high recurrence might occur due to the underlying systemic condition, particularly in cases of subacute bacterial endocarditis; splinter hemorrhages are seen in multiple fingers.

How Can Splinter Hemorrhages Be Prevented?

• Look at the nails every day to rule out any abnormal changes.

• Cut nails properly and keep them clean.

• Use water-soluble nail lacquer to get delicate nails.

• Wash hands regularly to avoid infections.

• Wear gloves while gardening or cleaning.

• Avoid professional manicures in cancer chemotherapy.

• Avoid overpressure to prevent nail trauma.

• Vitamin C enriched food intake.

What Are the Diagnosis and Tests for Splinter Hemorrhages?

A detailed history and a proper physical examination are important to diagnose splinter hemorrhages. With the help of dermatoscopy, the diagnosis is made clinically.

Laboratory diagnosis includes the following tests,

• Blood cultures and complete blood count (CBC) test- To detect any fungal infection in the blood.

• Erythrocyte sedimentation rate (ESR)- To detect inflammatory conditions in the body.

• Chest X-ray.

• Electrocardiogram.

• Echocardiogram.

• Biopsy- In the case of malignancies (for example, malignant melanoma).

• Dermoscopy - This skin surface microscopy, also called epiluminoscopy, is used to examine the skin and skin lesions, such as melanomas and malignant skin cancers.

How Are Splinter Hemorrhages Treated?

In the case of systemic conditions, treating the underlying cause is the treatment done to prevent splinter hemorrhages. There is no specific treatment for splinter hemorrhages caused due to physical trauma. In certain conditions like subacute bacterial endocarditis, proper medication and surgery are done to repair heart valves if necessary. Topical ointments are prescribed to prevent secondary infection. There is no specific remedy at home in case of splinter hemorrhages. It is a delayed symptom of endocarditis, so visit a doctor before it gets worse.

Conclusion

Splinter hemorrhages are the tiny blood spots (black lines or spots) seen underneath the fingernails. It is a late symptom of severe systemic conditions caused by various environmental and genetic factors (triggers). Therefore, getting help from a physician is preferable to treating the disease. Proper treatment and follow-up are essential. In addition, a person should maintain proper hygiene and keep the body and hands clean to avoid infections.