Splinter hemorrhages

Subungual, fine, longitudinally running, dark red or black, painless or only slightly pressure-sensitive, hemorrhagic line markings on the nail edge of the fingernails and toenails (toenails are less frequently affected, but are also less often carefully examined).

They originate in the epithelium of the nail bed and consist of blood and blood components in the stratum spinosum, which is attached to the underside of the nail.

Splinter hemorrhages grow along with the nail and can be removed mechanically at the free edge of the nail.

Distribution and color pattern (fresh hemorrhage = purple - old hemorrhage = black) as well as localization (distal third of the nail) vary, as does painlessness or painfulness.

• Idiopathic
• Acute and chronic traumas (crush trauma, tensile trauma caused by lifting the nail)
• Systemic Scleroderma
• Medicinal (e.g. cytostatics, multikinase inhibitors)
• Psoriasis vulgaris (see below psoriasis of the nails)
• Onychomycosis
• Mitral valve stenosis
• Cirrhosis of the liver
• Chronic dialysis
• Embolic events in endocarditis lenta or phospholipid-antibody syndrome
• Scurvy
• Streptococcus infections

The cause of splinter hemorrhages has previously been thought to be embolic events, such as in endocarditis lenta, phospholipid antibody syndromes, or granulomatosis with polyangiitis (Laurent C et al. 2019).

In bacterial endocarditis, Osler nodules as well as Janeway stains may additionally be of diagnostic importance.

Splinter hemorrhages also occur in healthy individuals but are usually confined to one finger and are traumatic in origin. A toxic cause cannot necessarily be assumed.

Splinter hemorrhages were rarely observed during therapy with imatinib, doxycycline, pacliataxel, doxetaxel.

The large number of diseases in which splinter hemorrhages can occur significantly limits the diagnostic value of this phenomenon.

1. Kolla PK et al (2012) Cutaneous manifestations in patients with chronic kidney disease on maintenance hemodialysis. ISRN Dermatol doi:10.5402/2012/679619
2. Laurent C et al (2019) Splinter haemorrhages, splenic infarcts, and pulmonary embolism in granulomatosis with polyangiitis.Vasc Med 24:263-264.
3. Palmou N et al (2011) Linear pitting and splinter haemorrhages are more commonly seen in the nails of patients with established psoriasis in comparison to psoriatic arthritis. Dermatology 223:370-373
4. Sethi K et al (2013) Splinter haemorrhages, Osler's nodes, Janeway lesions and Roth spots: the peripheral stigmata of endocarditis. Br J Hosp Med(London) 74: C139-142