Many different types of fibroma may occur in and around the nail (Figure 5.19). They may be true entities or merely variants of one process.


Hypertrophic scars and keloids result from injuries to the nail fold or nail bed and may significantly distort the nail apparatus.


Nail apparatus dermatofibromas are rare and may resemble cutaneous horns, fibrokeratomas or supernumerary digits; the latter, however, usually arise on the ulnar aspect of the fifth metacarpophalangeal joint. The histological changes include areas of thick, hypocellular, hyalinized collagen bundles, randomly orientated; there is an ill-defined nodule situated mainly in the reticular dermis; elastic fibres are often scarce or absent.

Koenen's tumour

Koenen's periungual fibromas develop in 50% of cases of tuberous sclerosis (epiloia or Bourneville-Pringle disease). They usually appear at about 12-14 years of age and increase progressively in size and number with age. Individual tumours are small, round, flesh-coloured and asymptomatic, with a smooth surface (Figures 5.20, 5.21). The tip may be slightly hyperkeratotic, resembling fibrokeratoma. The tumors grow out from the nail fold, eventually overgrowing the nail bed and destroying the nail plate. Depending on their site of origin, they may cause longitudinal depressions in the nail plate. Excessively large tumours are often painful, requiring excision. Histological changes consist of dense angiofibrotic tissue, sometimes with neuroglial tissue at the centre, and hyperkeratosis at the tip.

Figure 5.19

Periungual fibroma. (Courtesy of Akiro Kamumochi, Japan.)

Figure 5.19

Periungual fibroma. (Courtesy of Akiro Kamumochi, Japan.)

Avulsed Nail Tumor

Figure 5.20

Koenen's tumour associated with nail plate destruction.

Figure 5.20

Koenen's tumour associated with nail plate destruction.

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Figure 5.21

Multiple Koenen's tumours.

Koenen's tumours are cured by simple excision. Usually no suture is necessary. Tumours growing out from under the proximal nail fold are removed after reflecting the proximal nail fold back by making lateral incisions down each margin in the axis of the lateral nail grooves. Subungual fibromas are removed after avulsion of the corresponding part of the nail plate.

Acquired periungual fibrokeratoma

Acquired periungual fibrokeratomas are probably identical to acquired digital fibrokeratomas and Steel's 'garlic clove' fibroma. They are acquired, benign, spontaneously developing, asymptomatic nodules with a hyperkeratotic tip and a narrow base (Figures 5.22, 5.23). They most commonly occur in the periungual area or on other parts of the fingers. A case was described in which the lesion was located beneath the nail, visible under the free margin of the great toe nail. Most periungual fibrokeratomas emerge from the most proximal part of the nail sulcus growing on the nail and causing a sharp longitudinal depression. Trauma is thought to be a major factor initiating acquired periungual fibrokeratoma.

Microscopically, acquired periungual fibrokeratomas resemble hyperkeratotic 'dermal hernias'. The core consists of mature eosinophilic collagen fibres oriented along the main vertical axis of the tumour. The fibroblastic cells are increased in number. Most fibromas are highly vascular. The epidermis is thick and acanthotic. There is a marked orthokeratotic horny layer, which may be parakeratotic and contains serum or blood at the tip of the tumour. Elastic fibres are normal. Acid mucopolysaccharide levels are not increased.

Acquired Digital Fibrokeratoma

Figure 5.22

Acquired fibrokeratoma.

Sub Ungual Fibrokeratoma

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  • Ralph
    How to remove periungual fibrokeratoma?
    8 years ago
    What causes periugual fibromas?
    8 years ago
  • Darren
    How to remove periungual fibroma?
    4 years ago
  • Benito
    How to remove periungual fibromas?
    7 months ago
  • taziana
    What CPT code for removal of periungual fibroma?
    2 months ago

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