Splinter hemorrhages by medical definition, is small linear subungual hemorrhage which is red when fresh and brown when aged, located at the distal one-third of the nail bed, and is classically associated with mitral stenosis. Splinter hemorrhages are also seen in subacute bacterial endocarditis infection. Splinter hemorrhages can occur in all age groups but it is quite 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 a common feature seen in individuals with certain underlying systemic conditions.

Age: High in older people.
Sex: Men are more susceptible than females.
Other: Most common clinical feature in people with systemic conditions.

What Does a Splinter Hemorrhage Look Like?

Splinter hemorrhages are seen as red blood spots under the nails, which cause bleeding initially. It appears longitudinal, following the direction of the blood capillaries situated at the distal end of the nail beds. As the name splinter knows it, it appears as small thin blood streaks on nails. It can be present as a single line in a number or multiple. 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: 1mm to 3mm.
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 of that they are longitudinal in nature. It is found that 15 % to 30 % of splinter hemorrhages are seen in association with Osler and Janeway lesions. Splinter hemorrhages are seen in skin diseases like psoriatic nail disease and lichen planus.

Other 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 (psoriasis, lichen planus).
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3. Connective Tissue Disorders And Vasculitis.

Wegener's granulomatosis.
Digital vasculitis.
Medium vessel vasculitis.
Systemic juvenile idiopathic arthritis.

4. Infectious Diseases.

Subacute bacterial endocarditis.
Psittacosis.
Endarteritis.
Meningococcemia.

5. Renal diseases.

Hemodialysis.
Renal transplantation.

6. Drug-induced splinter hemorrhages.

Tyrosine -kinase inhibitors (Sunitinib, Sorafenib).
Ganciclovir.
Nitrofurantoin.
Terbinafine.

7. Idiopathic Splinter Hemorrhages.

Elder age.
High altitude.
Longitudinal erythronychia.
Idiopathic splinter hemorrhage (playing percussion instruments, household work, sports activities, and certain nail-related habits).

8. Miscellaneous.

Melanoma.

Splinter hemorrhages due to the injury of blood vessels or microemboli in systemic diseases include vasculitis, systemic lupus erythematosus, Raynaud's disease, Behcet disease, 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), 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 loss 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 to Prevent Worsening the Condition?

Look at your nails every day to rule out any abnormal changes.
Cut your nails properly and keep them clean.
Use water-soluble nail lacquer to get delicate nails.
Wash your 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.

How Long Can Splinter Hemorrhages Last?

The splinter hemorrhage healing process usually takes 3-4 months. The splinter hemorrhages will disappear as the nails grow over time.

How to Diagnose 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,

Blood cultures-To to detect any fungal infection in the blood.
Complete Blood Count (CBC).
Erythrocyte Sedimentation Rate (ESR) in inflammatory conditions.
Chest x-ray.
Electrocardiogram.
Echocardiogram.
Biopsy- in the case of malignancies(for example, Malignant Melanoma).

Is There Any Treatment?

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 to do at home in case of splinter hemorrhages. It is one of the delayed symptoms of endocarditis, so visit a doctor before getting worse.

Conclusion

Splinter hemorrhages are the tiny blood spots that are seen underneath the fingernails. It is a late symptom of severe systemic conditions. Getting help from a physician is preferable to treat the disease. Proper treatment and follow-up are essential. This take-home message is to keep your body and hands clean to avoid infections.