H09 Sir Jonathan Hutchinson’s melanotic whitlow: evolution of Hutchinson’s sign

Abstract

‘It needs sometimes, the eye of faith to recognize the narrow band of black which borders the inflamed part’. – Hutchinson J. Notes towards the formation of clinical group of tumors. Am J Med Sci 1886; 91: 470.

This groundbreaking observation by Sir Jonathan Hutchinson in 1886, initially termed the ‘melanotic whitlow’, refers to pigmentation change in the nailfold, often accompanied by painful inflammation. Historically such lesions were considered traumatic; however, through careful clinical observation and meticulous documentation, Hutchinson recognized that this manifestation could be associated with malignancy. The melanotic whitlow later evolved into the eponymous Hutchinson sign, which we continue to use in today’s assessment of melanonychia. Sir Jonathan Hutchinson was born in 1882 in Selby, emerging from a modest background to become a pioneering figure in 19th-century medicine. He was a distinguished British surgeon and pathologist with an interest in dermatology, ophthalmology, neurology and the study of syphilis. More than a clinician, Hutchinson was a dedicated teacher, writer and philanthropist, actively sharpening medical education and research, with his medical bibliography consisting of over 1000 published reports. His work traversed a diverse range of medical domains, with numerous eponyms across various fields attributed to him. In dermatology, we commonly know him for Hutchinson freckle (lentigo maligna) and use Hutchinson sign to describe the periungual extension of a longitudinal pigmented band onto the nailfold, typically representing progression of subungual melanoma. Although it remains a crucial diagnostic marker of subungual melanoma, our understanding of this phenomenon and our ability to detect it have evolved over the last century. Over time the term ‘pseudo-Hutchinson sign’ has been coined as a mimic of Hutchinson sign due to the reflection of pigmentation of the nailbed and nail matrix through a transparent nailfold. This is seen in nonmelanoma conditions such as Bowen disease, ethnic melanonychia, nail naevi, subungual haematoma, Peutz–Jeghers or Laugier–Hunziker syndrome, and other inflammatory pathologies. Further evolution of this eponym can also be attributed to the advent of dermoscopy. The aptly named micro-Hutchinson sign, describes the dermoscopic detection of subtle cuticular pigmentation, often elusive to conventional naked-eye examination, and is thought to be indicative of malignancy. Hutchinson’s detailed description of the melanotic whitlow has contributed significantly to our assessment of nail pigmentation and melanoma. From his first description of the ‘narrow band of black’ to Hutchinson sign, we now have three variations of this eponymous term, used widely by modern-day dermatologists and aiding in the analysis of melanonychia.