Treating A Patient With A Nail Unit Tumor

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Tracey Vlahovic, DPM

   Wart. Verrucae are a result of human papillomavirus (HPV) infection of the epithelium. These benign, hyperproliferative lesions typically have a hyperkeratotic covering and are flesh colored. Periungual verrucae can cause damage to the nail unit depending on the location.3 They can present on both fingernails and toenails. A wart often stems from nail biting and may recur after treatment. Management of these lesions can range from topical therapy (cryotherapy, salicylic acid) to surgical excision.

What You Should Know About Fibromas

The clinical diagnosis was acquired periungual fibrokeratoma. Fibromas are generally slow growing, painless tumors of the nail unit that can develop in any subepidermal structure. True fibromas are smooth and have a pea-like appearance. If occurring near the nail matrix, they will generally cause nail dystrophy. Depending on the location of the tumor, the nail dystrophy may manifest as nail thinning or as a depression in the nail plate.

   Acquired periungual fibrokeratomas are histologically separate from true fibromas but also may cause nail plate dystrophy. These benign nodules have a hyperkeratotic tip, emerge from the proximal aspect of the nail unit and are thought to be caused by trauma.4 In addition to their flattened flesh-colored appearance on the superficial aspect of the nail plate, acquired periungual fibrokeratomas may also have a filamentous, rounded appearance, which has caused some practitioners to call these lesions “garlic clove” fibromas.

   It is unknown how frequently these occur. Since there is no reporting system for these lesions, a review of the literature yields numerous case presentations. Acquired periungual fibrokeratomas present in both sexes and reportedly occur in people ranging from 12 to 70.5 In younger children, it may represent a supernumerary digit.

Pertinent Pointers On The Treatment Plan

The aforementioned patient and his parent consented to an excision of the lesion. I explained to the patient that after removing the tumor and subsequently reducing pressure on the matrix that the nail may grow back without the depression.

   I also explained to the patient that the tumor may recur due to the continuing trauma from sports or not excising it completely. In order to visualize the most proximal border of the lesion, I incised and dissected the proximal nail fold. I excised the lesion in toto and sent it for histopathologic examination. I sutured the proximal nail fold in place and gave wound care instructions.

   Following the excision, the patient had an uneventful postoperative course. The six-month follow-up visit showed nail plate restoration at the site of the excised lesion and no recurrence. The patient then received a prescription for a topical product consisting of poly-ureaurethane 16% (Nuvail, Innocutis) to assist in filling in ridges and provide protection from everyday trauma.

   Biopsy is recommended for nail unit tumors as entities such as Bowen’s disease (squamous cell carcinoma in situ) can masquerade as periungual fibrokeratoma. In cases such as this one, surgical excision was both diagnostic and curative.

   Dr. Vlahovic is an Associate Professor and J. Stanley and Pearl Landau Fellow at the Temple University School of Podiatric Medicine.

1. Solivan GA, Smith KJ, James WD. Cutaneous horn of the penis: its association with squamous cell carcinoma and HPV-16 infection. J Am Acad Dermatol. 1990; 23(5 Pt 2):969-72.
2. Devi B, Dash M, Behera B, Puhan MR. Multiple Koenen tumors: An uncommon presentation. Indian J Dermatol. 2011; 56(6):773-5.
3.  Patidar S. Combination treatment of periungual warts. J Cutan Aesthet Surg. 2008; 1(1):23–24.
4.  Bart RS, Andrade R, Kopf AW, Leider M. Acquired digital fibrokeratomas. Arch Dermatol. 1968; 97(2):120-9.
5.  Baykal C, Buyukbabani N, Yazganoglu KD, Saglik E. Acquired digital fibrokeratoma. Cutis. 2007; 79(2):129-32.

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