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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