Abstract
BACKGROUND: Subungual amelanotic melanoma (SAM) poses significant diagnostic challenges due to its rarity and nonspecific clinical manifestations, such as nail dystrophy or indurated plaque. CASE PRESENTATION: We present the case of a 60-year-old woman with a three-year history of recurrent serous drainage and persistent pain in her left middle finger following an initial crush injury. Over a period of two years, she underwent three nail avulsion procedures, received systemic antibiotic therapy, and was treated with topical Chinese herbal therapies under a presumptive diagnosis of "chronic onychia following trauma" at a local hospital. Additionally, PET-CT imaging demonstrated localized inflammatory changes without evidence of neoplastic disease. Despite these interventions, the lesion remained refractory to treatment. A thorough reevaluation conducted by our department, incorporating histopathological and immunohistochemical analyses, ultimately confirmed the diagnosis of SAM. CONCLUSIONS: This case underscores the importance of maintaining a high index of suspicion for SAM when evaluating atypical nail lesions. A low threshold for nail biopsy in cases of prolonged swelling and exudation of a single nail is advised. Additionally, prior trauma to the nail may contribute to the development of SAM through post-traumatic immunosuppression and persistent low-grade chronic inflammation. However, the exact role of trauma in the pathogenesis of melanoma remains unclear and requires further investigation.