Squamous cell carcinoma of the nail apparatus has a good prognosis compared with other sites

Trauma, chronic infection and chronic radiation exposure are possible aetiological factors; human papillomavirus (HPV) has been incriminated in some cases. Two reported cases had associated congenital ectodermal dysplasia. Most lesions occur on the fingers, particularly the thumbs and index fingers (Figure 5.31). The presenting symptoms include pain, swelling, inflammation, elevation of the nail, ulceration, a tumour 'mass', ingrowing of the nail, 'pyogenic granuloma' and bleeding. Bone involvement is a rare, very late sign. The duration of symptoms before diagnosis is greater than 12 months in over half the cases. Only in one published case (with ectodermal dysplasia) has the condition led to death, from rapid generalized metastases.

Subungual squamous cell carcinoma is slow-growing and may be mistaken for chronic infection. This frequent misdiagnosis unduly prolongs the period between the onset of the disease, diagnosis and therapy. Often it is not possible to determine whether the tumour was present initially or developed later, secondary to trauma, warts or infection. As mentioned above, invasive squamous cell carcinoma may develop from Bowen's disease. The possibility of a link with HPV strains 16, 34 and 35 sheds new light on the aetiology of this type of cancer and suggests a logical cause for multiple digital Bowen's disease.

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