Periungual and subungual warts

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

Amelanotic

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

Irradiation

Laugier-Hunziker-Baran syndrome Onychomycosis nigricans

Epidermal cyst Exostosis

Foreign body granuloma

Metastasis

Onychomatricoma Keratoacanthoma

Pyogenic granuloma

Ingrowing nail_

PUVA, psoralens with long-wave ultraviolet irradiation.

Foreign Body Granuloma
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