Dermatology expert witness opines on undiagnosed cancerous nail lesions

This case takes place in Alaska and involves a forty-two-year-old female patient with no significant past medical history. The patient made repeated complaints to her primary care physician about of the unusual appearance of the fingernail of her right thumb. The nail was discolored and the surface with bumpy and raised. The patient’s primary care physician remained unconcerned about the nail lesion, advising that the appearance was most likely due to a fungal infection. The patient sought treatment using over the counter, topical anti-fungal ointments. None of these treatments were effective in improving the condition of the nail. Sometime later the patient complained of an open wound developing on the thumb nail area, which would not heal. Finally, after over a year of seeking treatment from her primary care physician and several months of attempted self-treatment, the patient saw a dermatologist. The dermatologist examined the nail and ordered a punch biopsy. The punch biopsy was interpreted as negative and the dermatologist continued to treat this patient for almost a year with no signs of improvement. Eventually, after a long period of unsuccessful treatment, the patient consulted a wound specialist, who removed the nail entirely and ordered a proper biopsy. The patient was diagnosed with melanoma and required a thumb amputation. Unfortunately, the cancer had already metastasized to the patient’s lymph nodes and she was subsequently diagnosed with stage III cancer.

Question(s) For Expert Witness

The patients treating dermatologist continued to treat the patient for 8 months, without referring her to a wound care specialist or ordering a subsequent punch biopsy - yet the patient’s condition continued to decline and there were no signs of improvement. Is this a departure from the standard of care?

Expert Witness Response E-004759

In most cases, if a diagnosis of melanoma is suspected, when a lesion is present on the patient’s nail (if that was one of the concerns), the entire nail must be removed as a nail matrix biopsy must be done. The punch biopsy would not have been an adequate diagnostic tool as the nature of the investigation may risk an unaffected area being sampled, as seems to be the case for this patient. This would result in a false negative result. The standard of care would dictate that if there were no signs of improvement after two to three months, of treatment the dermatologist should have done a repeat biopsy at that time. It represents a departure from the standard of care for the dermatologist to continue treatment for eight months with no repeat biopsy.