Question 2 What Is A Tumor Of The Nail (Or Nail Bed) Called?

Volume 42, Upshot 4, Apr 2013

Subungual nodule of the nifty toe

Paulo Morais

Figure 1. Clinical appearance of the lesion located on the patient's right great toe

Effigy 1. Clinical appearance of the lesion located on the patient's correct great toe

Question 1

What is the most probable diagnosis?

Question ii

What is the aetiology of this condition?

Question iii

How is this condition diagnosed?

Question four

What are the differential diagnoses?

Question five

What is the appropriate direction of this condition?

Answer 1

The most likely diagnosis is subungual exostosis (SE). Subungual exostosis is an uncommon, tiresome growing, benign osteocartilaginous tumour arising from the distal phalanx of a digit, beneath or adjacent to the boom bed. Dupuytren first described the status in 1817.^1,ii

Answer two

The precise aetiology of SE is unknown. It was previously considered to exist a rare variant of osteochondroma. However, information technology is a reactive metaplasia of cartilage and is clinically, developmentally, radiographically and histologically singled-out from osteochondroma.³ Associated factors such every bit trauma, chronic irritation to the bone and longstanding infection have been documented,^1,2 all the same, chronic infection seems to be the effect rather than the crusade of this lesion.²

More recently, a balanced chromosomal translocation [involving t(X;6)] has been reported in a small series of patients with SE, which supports a neoplastic rather than a reactive process.^four In some cases, SE may be a manifestation of one of two inherited conditions: multiple exostoses syndrome and multiple exostoses-mental retardation syndrome (also called Langer-Giedion syndrome, trichorhinophalangeal syndrome type II, Alè-Calò syndrome or MEMR syndrome).⁵

Answer 3

Clinical advent and radiographic findings are sufficient to confirm a diagnosis of SE. Clinically, SE appears equally a house and stock-still subungual nodule that elevates the blast plate and produces distal or lateral onycholysis. Due to the pressure issue on the nail bed and plate, it tends to be painful and can result in nail plate deformity or destruction. Over time, ulceration and paronychial infection can occur. Although they can involve any digit, 70–lxxx% of lesions are found on the great toe, normally on the dorsal or dorsomedial aspect of the distal phalanx.

A college frequency of SE is seen in children and young adults with a slight preponderance in girls and women.^1,2,6 Subungual exostosis has feature radiographic features, and early use of radiography tin prevent an incorrect diagnosis and inappropriate handling, which can atomic number 82 to recurrence or unnecessary amputation.^1,2 An Ten-ray showing an exophytic lesion on the dorsal surface of the distal phalanx is diagnostic.²

Answer 4

Conditions to exist considered in the differential diagnosis of SE are listed in Table 1.^1,2,6 Well-nigh of these conditions tin can be easily differentiated from SE based on clinical features and/or Ten-ray findings. Even so, biopsy for histological test may occasionally be necessary in lodge to establish the diagnosis.

Tabular array 1. Conditions to consider in the differential diagnosis of subungual exostosis
Disease	Differentiating features
Ingrown toenail (onychocryptosis)	A painful, swollen, and tender toe, with crusting, purulent discharge, and friable or macerated granulation tissue at one or both sides of the boom bed
Verruca vulgaris (viral wart)	Skin coloured or grayish plaque with a papillomatous, raised, thick and hyperkeratotic surface. Black dots (thrombosed superficial capillaries) may be present on the surface. Can originate from the boom folds or the hyponychium and spread to the boom bed. Onycholysis, onychodystrophy and/or pain may occur
Pyogenic granuloma	Chop-chop growing, exophytic papulonodule affecting the nail fold or hyponychium. Colour ranging from bright crimson to blue-imperial. Size may vary from millimetres to centimetres. May feature an ulcerated, erosive or friable surface, which bleeds easily
Glomus tumor	Small red-blue patch or nodule under the nail plate, usually on the fingernails and associated with paroxysmal pain, tenderness, and temperature sensitivity. Pain may be provoked past mild trauma and radiate to the limb. The nail may exist ridged or dystrophic^viii
Osteochondroma	Subungual location is quite rare. Well defined, house, and often painful exophytic tumour causing onycholysis of the nail plate. Normally appears more proximal than a SE, and is often larger in size. Definitive diagnosis dependant on microscopic evaluation of the excised specimen (distinctive hyaline cartilage)³
Lipoma	Extremely rare in the nail unit of measurement. May present as a soft, mobile, and usually asymptomatic nodular neoplasm, located subungually or in the lateral fold
Fibroma/fibrokeratoma	Painless, slow growing, nodular or filiform (sausage-like) lesion, often with a keratotic surface, usually arising from beneath the proximal nail fold and causing a longitudinal depression. Subungual lesions are uncommon and ordinarily result in onycholysis. Multiple periungual fibromas (Koenen tumors) can occur in patients with tuberous sclerosis⁸
Keratoacanthoma	Rapidly growing, painful, well demarcated, dome-shaped nodule with a central keratin plug. If left, spontaneous involution occurs, leaving a pocket-size, pitted scar. May involve the hyponychium or the proximal boom fold and sometimes also affects the underlying bone. May be locally subversive. Difficult to distinguish from SCC and cancerous transformation to SCC occurs rarely^viii,9
Squamous jail cell carcinoma (SCC)	In situ SCC (Bowen disease): warty plaque, usually in fingernails; sometimes presents as periungual erythema associated with crusting, ulceration or fissuring, paronychia, longitudinal melanonychia or nail dystrophy^8,10 SCC: slowly growing subungual nodule that eventually ulcerates and bleeds, or a wart-like periungual growth. The underlying os is commonly involved. More common in the fingernails and after the 5th decade of life^8,x
Subungual malignant melanoma	Rare form of melanoma, most mutual in middle aged or elderly patients, especially on the thumb or hallux. May arise within the nail matrix or bed. Longitudinal melanonychia and Hutchinson sign (periungual brown-black pigmentation) are typical. Dermatoscopic examination is useful. Lesion is amelanotic in 25% of cases. May develop a ordinarily painless nodule under the blast plate, with ulceration, bleeding and onycholysis^8,11

Reply 5

Surgical excision is the advisable management of this condition. The full general practitioner can perform this in the dispensary, merely GPs unfamiliar with the procedure may prefer to refer to a general surgeon. Excision is ordinarily performed under digital block anesthaesia. A bourgeois approach under the nail and preserving smash coverage is often possible. The pare is incised and the bony lesion dissected. It is then clipped off at its base using a bone rongeur or a strong blast clipper, followed by curettage of the distal phalanx with a bone curette. The wound is closed with unproblematic sutures.

If the exostosis is located more than proximally under the nail plate, the nail plate may need to be partially or totally avulsed to facilitate the entire removal of the lesion. A technique in which nail plate is sutured dorsum into identify later removal of the exostosis has also been described.^{4,half dozen,7} Incomplete surgical resection may consequence in local recurrence. A recurrence rate of five–eleven% has been reported.ⁱⁱ Yet, no case of malignant transformation has been reported.^2,6

Case report follow upwards

Because of the degree of nail deformity and onycholysis, the patient required a complete smash plate resection. The tumour was removed and histology showed mature trabecular os covered by hyaline fibrocartilage tissue, confirming the diagnosis of subungual exostosis.

Competing interests: None.
Provenance and peer review: Not commissioned; externally peer reviewed.

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