Figure 523

'Garlic clove' fibrokeratoma.

Surgical treatment is the same as for Koenen's tumours and depends on the size and location of the lesion.

The differential diagnosis of acquired periungual fibroma includes:

• recurring digital fibrous tumours of childhood

• dermatofibrosarcoma

• fibrosarcoma

• acrochordon

• cutaneous horn

• eccrine poroma

• pyogenic granuloma

• verruca vulgaris

Subungual filamentous tumour

Subungual filamentous tumours are thread-like, horny, subungual lesions growing with the nail plate and emerging from under the free edge of it. They may cause a longitudinal rim. This entity is probably a narrow, extremely hyperkeratotic fibrokeratoma; it can be pared down painlessly when the nail is cut.

Recurring digital fibrous tumours of childhood (benign juvenile digital fibromatosis)

Recurring digital fibrous tumours are round, smooth, firm tumours with a reddish or livid red colour. They are located on the dorsal and axial surfaces of the fingers and toes, characteristically sparing the thumbs and great toes (Figure 5.24). They may present at birth or develop during infancy, although a single case of presentation in adulthood has been described. There is no sex predominance. Fingers are more often affected than toes. On reaching the nail unit the tumours may elevate the nail plate, leading to dystrophy but not to

Figure 5.24

Benign juvenile digital fibromatosis (Courtesy of C.Moss, UK.)

Figure 5.24

Benign juvenile digital fibromatosis (Courtesy of C.Moss, UK.)

destruction. Often the tumour is multicentric, occurring on several digits. Although an infectious origin is probable, no virus has been isolated and viral particles have not been demonstrated by electron microscopy. Up to 60% recur after excision. Spontaneous regression was noted in 5 out of 61 cases; regression may be hastened by cryosurgery. Radical surgical ablation of the area involved may rarely be necessary, including the nail unit, leading to permanent loss of the nail. Firm plantar nodules may be associated with these tumours.

Histological examination shows a diffuse, proliferative, cellular process in the dermis with increased numbers of apparently normal fibroblasts with uniform, spindle-shaped nuclei. Mitoses are absent or rare. Elastic tissue is decreased. In about 2% of the fibroblasts, paranuclear inclusion bodies, 3-10^m in diameter, can be seen in adequately fixed specimens with the use of stains such as iron haematoxylin, methyl green-pyronin and phosphotungstic acid-haematoxylin. Electron microscopy shows that the inclusions consist of fibrillar masses without a limiting membrane. On the basis of this evidence, it has been suggested that the condition should be termed 'elastodysplasia'.

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