A splinter hemorrhage is a small, stripe-shaped hemorrhage under the toenail or fingernail, which looks like a splinter. A splinter hemorrhage is the result of small blood spots under the nails, causing streaks under the nails. These stripes darken over several days. The two most common causes of splinter hemorrhages following injury or trauma to a fingernail or toenail are bacterial endocarditis and scleroderma. Bacterial endocarditis involves an infection in the endocardium (the inner lining of the heart). If there is an underlying condition, it can be treated with medication and/or surgery. Often the splinter hemorrhage disappears after treatment of the underlying cause, but occasionally it is permanent. In most people, the prognosis of splinter hemorrhage is excellent. In some cases, the prognosis depends on the severity of the underlying condition that caused the splinter hemorrhage.

• What is a splinter hemorrhage?
• Symptoms of a splinter hemorrhage
• Causes of a (splinter) stripe under the nail

• Injury or injury
• Bacterial endocarditis
• Systemic diseases
• Systemic lupus erythematosus
• Scleroderma
• Vasculitis
• Rheumatoid vasculitis in rheumatoid arthritis
• Fungal infection of the nail
• Diabetes
• Raynaud’s phenomenon
• Cholesterol
• Side effect of medications
• Nail psoriasis
• Without known cause

• Who gets it?
• Complications
• Contact with GP
• Examination and diagnosis

• Interview and physical examination
• Follow-up research

• Treatment of splinter hemorrhage
• Prognosis
• Prevention

What is a splinter hemorrhage?

Splinter hemorrhages (splinter hemorrhages, hemorrhages, splinter bleeding) are small blood spots that appear under the nail and look like splinters. A splinter hemorrhage causes longitudinal stripes under the nails, in the direction of nail growth. A splinter hemorrhage occurs when capillaries in the nail bed are damaged and burst. Some splinter hemorrhages can be an indicator of an underlying disease. However, a splinter hemorrhage is sometimes just a harmless abnormality that can occur in the body. Splinter hemorrhages can occur on your toenails or fingernails.Splinter hemorrhage / Source: Splarka, Wikimedia Commons (Public domain)

Symptoms of a splinter hemorrhage

The hallmark symptom of a splinter hemorrhage is a small amount of blood under a nail. You may see a dark red, brown to black line under the nail. The dark stripe looks a lot like a splinter under the nail. A splinter hemorrhage usually does not cause pain. You may not even notice the bleeding right away. An exception is when a splinter hemorrhage is the result of an injury to your toe or finger. In that case, you may have swelling, inflammation, and pain, along with a small amount of blood under the nail.

Causes of a (splinter) stripe under the nail

A (splinter) stripe under the nail is often caused by injury or trauma to the fingernail or toenail. Sometimes a splinter hemorrhage occurs even though no injury has occurred. This could then be a symptom of another underlying condition. The cause is not always discovered.

Injury or injury

Bleeding can occur as a result of a physical injury to the nail bed, which you may have sustained while playing a sport (tennis, hockey, etc.) or doing your job (electrical or pneumatic equipment). These bleeding spots usually disappear on their own once the physical trauma heals. It takes a few months for the completely healthy nail to grow back.

Bacterial endocarditis

Endocarditis occurs when bacteria or other pathogens enter the bloodstream through wounds in the skin, intestines or gums and ultimately reach the heart. This is an infection that affects parts of the endocardium, the inner lining of the heart. Rarely, someone with endocarditis may develop extensive splinter hemorrhages from the nail beds. However, these patients are seriously ill and you can therefore expect that such individuals are already under medical treatment.

Systemic diseases

When splinter hemorrhages occur on multiple nails, this may indicate a systemic disorder. In addition to occurring in larger numbers in these situations, they are also much more common and in more places. In this situation they may be a sign of a connective tissue disorder, such as lupus or scleroderma (see below).

Systemic lupus erythematosus

Systemic lupus erythematosus or SLE, often referred to simply as lupus, is a chronic inflammatory disease. You can get inflammation anywhere in the body, but the most common areas are the skin, joints, kidneys, lungs and brain. Some people with lupus also experience splinter hemorrhages.

Scleroderma

Scleroderma is an autoimmune disease that causes your skin to tighten and the connective tissue in your organs to increase. Scleroderma is a very rare disease; approximately 1 in 10,000 people suffer from it. In 2023, no clear cause of scleroderma is recognized.

Vasculitis

Vasculitis is an inflammation of the walls of the blood vessels. This can also occur under the nails, where splinter bleeding can occur.

Rheumatoid vasculitis in rheumatoid arthritis

Rheumatoid vasculitis is a late complication of rheumatoid arthritis (RA) that can involve the skin and other organs and affect vessels of any size. Rheumatoid vasculitis can result in various skin signs and is most common in long-term RA, especially in men. This can lead to symptoms such as petechiae or pinpoint hemorrhages and purpura, splinter hemorrhages, small spots around the fingernail (Bywater’s lesions) and peripheral neuropathy, a dysfunction of one or more peripheral nerves.

Fungal infection of the nail

Fungal infections of the nail (fungal nail) can cause the nail bed to thin and possibly cause blood vessel damage.

Diabetes

High glucose levels in uncontrolled or undiagnosed diabetes can damage blood vessels and can lead to splinter hemorrhages under the nail.Raynaud’s phenomenon / Source: Tcal, Wikimedia Commons (CC BY-SA-3.0)

Raynaud’s phenomenon

Splinter hemorrhages may also be seen in individuals who have Raynaud’s disease. This causes small arteries to temporarily cramp, reducing the supply of blood to the underlying tissues, causing attacks of cold, numb and sometimes painful fingers or toes. At the same time that the splinter hemorrhages occur, pink, blue, or white discoloration of the fingertips may also be present. In most patients with Raynaud’s disease it is not associated with a serious underlying systemic condition, but on occasion it can also be a manifestation of a connective tissue disorder such as lupus or scleroderma.

Cholesterol

Accumulation of cholesterol in the blood vessels of the fingernails can cause damage, which is visible by splinter hemorrhages under the nail.

Side effect of medications

Splinter hemorrhages can also occur as a side effect of certain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, diclofenac, meloxicam, naproxen, etofenamate, celecoxib. These medications can cause bleeding if taken in high doses.Nail psoriasis of the thumbnail / Source: Martin Sulman

Nail psoriasis

Nail psoriasis can manifest itself in many different ways, depending on the location of the inflammatory process. Involvement of the nail matrix causes pits in the nails, transverse grooves or lines in the nail (also called ‘Beau lines’), onychomadesis (a nail abnormality in which the nail separates from the nail bed at the top, i.e. near the cuticle), trachyonychia (thin nails with a rough surface), nail dystrophy (growth disorders of the nail) and leukonychia (white discolouration of nails, white spots on the nail), while psoriasis of the nail bed leads to onycholysis (nail detachment), ‘oil stain phenomenon’ (a yellow- brown discoloration of the nail plate, as if a drop of oil has run under it), subungual hyperkeratosis (thickening of the nail) and splinter hemorrhages.

Without known cause

In some individuals, the line under the nail appears due to the splinter hemorrhage without any known cause. Such cases are called ‘idiopathic’, meaning ‘without known cause’.

Who gets it?

Splinter hemorrhages can affect any person, regardless of age, gender, race, and ethnicity.

Complications

A splinter hemorrhage does not usually lead to serious complications. Complications can arise as a result of the underlying disease process.

Contact with GP

If you notice that a splinter hemorrhage occurs under the nail after you have suffered a nail injury, you can safely assume that it is a natural consequence of the trauma that does not require medical attention, unless there is a serious trauma and/or very severe trauma. a lot of pain. However, if you have not suffered any (recent) injuries to the nail and the dark nail lines are present or you suffer from recurring splinter bleeding, it is wise to make an appointment with your doctor. He can then check whether or not there is an underlying disease or condition.Blood test / Source: WathanyuSowong/Shutterstock.com

Examination and diagnosis

Interview and physical examination

In case of physical injury, the diagnosis is easy to make. But the other diseases require further research to determine their cause. In addition to an interview with the doctor and a physical examination, follow-up examinations may be necessary.

Follow-up research

Follow-up testing may include the following tests:

• blood test
• x-rays of the chest area
• electrocardiogram or ECG (ECG)
• echocardiogram (to image the heart and measure blood flow in the heart)

The tests will isolate the true disorder leading to splinter hemorrhages under the fingernails.Medication to treat the underlying condition of a splinter hemorrhage / Source: Stevepb, Pixabay

Treatment of splinter hemorrhage

Splinter hemorrhages caused by physical trauma usually resolve on their own without treatment; the place just grows out of it. The body’s ability to regenerate itself is remarkable in such cases.Provided there is no systemic disease, the splinter hemorrhages will disappear on their own. However, if the streaks under the nail have not disappeared after about three months, a visit to your doctor is recommended to determine the cause.Once the investigative tests have revealed the underlying disorder responsible for the splinter hemorrhages, treatment will begin. If the underlying condition is cured, the nail bed bleeding will automatically disappear. Treatment for bacterial endocarditis usually consists of medication and possibly surgery to repair the heart valves. For scleroderma, your doctor prescribes medications that slow the disease process. The treatment of vasculitis consists of calming the disease as quickly as possible with medication. Ointments or creams do not help with a fungal nail. Antifungal pills can sometimes help.

Prognosis

The outlook for splinter hemorrhages is often positive. When a splinter hemorrhage is caused by trauma, the line under the nail will grow out on its own without medical treatment. For the best possible outcome from splinter hemorrhages caused by an underlying disease or condition, it is important to adhere to the doctor’s treatment instructions. This may include discontinuing certain medications, as well as taking medications as prescribed.

Prevention

It is recommended that people with splinter hemorrhages exercise caution and do not aggravate the condition by:

• increased irritation of the affected area
• increased trauma to the nail

read more

• Brown or black streaks in nail: causes and treatment
• Remove splinter under nail: remove it yourself, doctor
• Brown nails: causes and symptoms of brown spots
• Treating fungal nails: what to do about fungal nails?
• Thick nails or thickened nails: symptoms and treatment