Periungual and subungual warts

Moles, Warts and Skin Tags Removal

Skin Tags Removal Guide By Charles Davidson

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Common warts are caused by human papillo-maviruses of different biological types (Figures 5.16-5.18). They are benign, weakly infective, fibre-epithelial tumours with a rough keratotic surface. Usually periungual warts are asymptomatic, although fissuring may cause pain. Subungual warts initially affect the hyponychium, growing slowly toward the nail bed and finally elevating the nail plate. Bone erosion from verruca vulgaris occasionally occurs—although some of these cases may have been keratocanthomas, since the latter, epidermoid carcinoma and verruca vulgaris are sometimes indistinguishable by clinical signs alone.

Table 5.2 Tumours of the nail unit (by site)_

At the nail fold/plate junction Acquired periungual fibrokeratoma Periungual fibroma (tuberous sclerosis) Within the nail fold Myxoid pseudocysts Tendon sheath giant cell tumour On the nail folds and nail walls Verruca vulgaris

Recurring digital fibrous tumour of childhood Within the nail bed with or without nail plate destruction

Subungual exostosis Osteochondroma Enchondroma Subungual corn (heloma) Pyogenic granuloma Glomus tumour

Recurring digital fibrous tumour of childhood Bowen's disease and squamous cell carcinoma Melanoma Metastases

Table 5.3 Differential diagnosis of subungual malignant melanoma

Malignant lesions_Benign lesions_

Pigmented Longitudinal melanonychia

Haemangioendothelioma Melanocytic hyperplasia

Kaposi's sarcoma Metastatic melanoma


Basal cell carcinoma Bowen's disease Squamous cell carcinoma

Junctional naevus Adrenal insufficiency Adrenalectomy for Cushing's disease Angiokeratoma

Chromogenic bacteria (Proteus)

Drugs: antimalarials, cytotoxics, arsenic, silver, thallium, phenothiazines and PUVA

Haematoma, trauma


Laugier-Hunziker-Baran syndrome Onychomycosis nigricans

Epidermal cyst Exostosis

Foreign body granuloma


Onychomatricoma Keratoacanthoma

Pyogenic granuloma

Ingrowing nail_

PUVA, psoralens with long-wave ultraviolet irradiation.

Subungual Wart

Figure 5.16

Periungual viral warts.

Recalcitrant Wart

Figure 5.17

Smaller proximal nail fold due to viral wart.

Figure 5.17

Smaller proximal nail fold due to viral wart.

Heloma Periungual

Figure 5.18

Subungual viral wart with nail plate destruction.

Figure 5.18

Subungual viral wart with nail plate destruction.

Table 5.4 Tumours and swellings affecting the nail apparatus (those in bold

_type are described in the text)_


Verrucous epidermal naevus Subungual papilloma Subungual onychopapilloma Verrucous lesions in incontinentia pigmenti Subungual corn Epidermoid cyst

Onychomatricoma Fibromatous lesions Keloids

Dermatofibroma Koenen's tumour

Acquired periungual fibrokeratoma Subungual filamentous tumour Benign juvenile digital fibromatosis Leiomyoma Giant cell tumour Xanthoma Lipoma

Neurogenic tumours Multicentric reticulohistocytosis Actinic keratosis Arsenical keratosis

Glomus tumour

Pyogenic granuloma

Naevus flammeus and angioma Angiokeratoma circumscriptum Aneurysmal bone cyst (arteriovenous fistula) Osteochondroma Subungual exostosis Enchondroma Maffucci's syndrome Osteoid osteoma

Hereditary multiple exostosis (diaphyseal aclasis)

Myxoid pseudocyst


Bowen's disease

Squamous cell carcinoma


Basal cell carcinoma


Kaposi's sarcoma



Melanotic/melanocytic lesions

Benign melanocytic hyperplasia Lentigo simplex and naevocytic naevus Atypical melanocytic hyperplasia Peutz-Jeghers-Touraine syndrome Malignant melanoma

Laugier-Hunziker-Baran syndrome_

Subungual warts are painful and may mimic glomus tumour. The nail plate is not often affected, but surface ridging may occur and, more rarely, dislocation of the nail. Biting, picking and tearing of the nail and nail walls are common habits in people with periungual warts. This type of trauma is responsible for the spread of warts and their resistance to treatment.

Tuberculosis cutis verrucosa (butcher's nodule) may rarely pose differential diagnostic problems, but it is unusual in the periungual location, affecting a lateral fold of the toe nails with long-standing warty lesions with unusual wart morphology. Bowen's disease must be considered, as should the subcutaneous vegetations of systemic amyloidosis.

Treatment of periungual warts is often frustrating. Treatments with X-rays and radium have become obsolete. Saturated monochloroacetic acid has been suggested, but is painful; it is applied sparingly, allowed to dry and then covered with 40% salicylic acid plaster cut to the size of the wart and held in place with adhesive tape for 2-3 days. After 1-2 weeks many of the warts can be removed and the procedure repeated. Subungual warts are treated similarly, after cutting away the overlying part of the nail plate. Recalcitrant warts may respond to weekly applications of diphencyprone solutions ranging from 0.2% to 2%, according to the patient's ability to produce a good inflammatory reaction. Some authorities recommend the use of cantharidin (0.07%); this is applied to the lesions and covered by a plastic tape for 24 h. The resultant blister should be retreated at 2-week intervals, three to four times if necessary. Bleomycin has also been recommended for recalcitrant warts; it is given intralesionally 1 pig per ml at 2-week intervals. Some patients find this more painful than correctly used cryosurgery.

Surgical treatment should be avoided if possible. Cryosurgery with carbon dioxide snow or liquid nitrogen is often used but may cause blistering, with the blister roof containing the epidermal wart component if the treatment succeeds. However, when treating the proximal nail fold freezing must not be prolonged since the matrix can easily be damaged; this may result in circumscribed leukonychia or even nail dystrophy, although scarring is rare with cryosurgery. Particular side-effects of cryosurgery include pain, depigmentation and secondary bacterial infection (rare), Beau's lines, onychomadesis, nail loss or inordinate oedema, the latter often worse in the very young and very old, and transient neuropathy or anaesthesia. Many of the side-effects are avoidable if the freezing times are carefully controlled and if prophylactic analgesic and subsequent anti-inflammatory treatment is given: soluble aspirin 600 mg three times daily for 5 days and topical steroid application twice daily. Destruction by curettage and electrodesiccation may produce considerable scarring. Infrared coagulation and argon and carbon dioxide laser treatments have been used with some success. If the most aggressive measures fail, or compliance is poor, formalin may be applied daily with a wooden toothpick. If the lesions become inflamed, fissured or tender, because of the therapy or secondary infection, treatment is interrupted and a topical antiseptic preparation used for several days. Many people have tricks for attempting to cure warts, such as 'wrapping', followed 2 weeks later by the careful application of liquefied phenol, then a drop of nitric acid to the lesion. The fuming and spluttering that occurs looks efficacious, and the wart turns brown.

Since the incubation period of human warts may be up to several months, consistent follow-up, even after seemingly successful therapy, is necessary to allow for early treatment of newly growing warts.

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