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Nail Tumors

A nail tumor is a lesion found under the nail plate. It is attached to the nail bed or matrix. Most tumor growths of the nail bed are benign, but some may be malignant. These need to be removed surgically. Benign and malignant tumors both affect the nail and cause a deformity.

The tumors could be myxoid cysts, pyogenic granulomas, glomus tumors, onychocytic matricoma, Bowen disease or squamous cell carcinoma, and malignant melanoma.

Myxoid Cysts

Myxoid cysts are actually called pseudocysts because they are not surrounded by a capsule. The cyst stems from the connective tissue on top of the last finger segment. It looks like a shiny papule at the edge of the nail. It is semi translucent and contains a sticky fluid that may be tinged with blood when expelled.

They are also known as myxoid pseudocyst, mucous cyst, digital ganglion cyst, and digital synovial cyst. Most are benign and can be treated by merely draining the fluid with a sterile needle. In severe cases, surgical intervention may be required. They tend to reoccur.

Pyogenic Granulomas

Pyogenic granulomas are slightly raised bumps caused due to excessive growth of capillaries. They cause a swelling of the surrounding tissue. They are about a quarter to three-forth inch in diameter and rise from the nail bed or the surrounding tissue. They may not be painful but tend to bleed very easily. The condition can affect anyone.

Most pyogenic granulomas are benign and will disappear after a while. They may also be surgically removed by the doctor by curettage or electrodesiccation. It is a good idea to get a biopsy of the tumor to ensure that it isn’t malignant. Pyogenic granulomas may regrow even after being removed.

Glomus Tumours

Glomus tumors are mainly found in subungual locations or under the nail. They are essentially a malformation of the veins rather than a skin tumor. They have also been found on the fingertip or in the foot. They arise from the glomus body and can affect toes or fingernails. They are mostly benign, but due to their small size can be difficult to diagnose. A biopsy must be conducted when possible

The tumors are classified into solitary, multiple or congenital. Another form is called glomangioma. This is usually reported at birth and is seen as a plaque-like lesion on multiple digits. Initially painless, they may later become tender to touch. Glomangiomas are inherited through autosomal dominant pattern, which means half of the children of an affected parent are likely to get it. Treatment includes laser removal, injection of hypertonic saline or sclerotherapy.

Onychocytic Matricoma

Onychocytic Matricoma is a tumor of the nail matrix. It is usually seen as a dark line under the nail. It is accompanied by localized thickening of the nail plate and melanonychia. Melanonychia refers to the brownish black discolouration of the nail. The tumor is keratogenous, which means it is caused by excessive production of keratin.

Treatment of Onychocytic Matricoma begins with exploration of the tumor which is then sent for a biopsy to check if it is malignant. Excision of the tumor may be enough for a benign lesion. Further options will be explored for a malignant tumor.

Bowen Disease or Squamous Cell Carcinoma

Squamous cell carcinoma is a skin cancer that affects the epidermis due to abnormal, uncontrolled growth of the squamous cells. The chief cause of the condition is high exposure to ultraviolet light. Men are twice as likely to get it as compared to women.  Besides the nails, it can affect any area of the body that is frequently exposed to the sun such as the face, hands, arms and legs. Rarely it may also affect the genitals and mucous membranes.

Bowen’s disease is restricted to the epidermis and has not usually gone into the deeper skin layers. It is called intraepidermal squamous cell carcinoma. Early detection and removal of the squamous cell carcinomas usually results in a complete cure. A biopsy is recommended. Surgery, radiation, electrosurgery, photodynamic therapy or laser treatment may be used. Prognosis is usually quite positive if the tumor is eliminated in time.

Malignant Melanoma

Melanoma is a type of skin cancer that affects melanin producing cells. Besides the skin, it can affect the eyes, nails and in rare cases the internal organs. It usually appears as a dark stripe on the nail. Commonly found on the great toe or the thumb, it may be present on any digit. Essentially it is the skin on the nail bed which develops the tumor.

Melanoma of the nail bed is also called subungal melanoma. It is called ungual melanoma when it originates from under the nail plate and periungual melanoma when it originates from the skin besides the nail plate.

Dark-skinned people are more likely to be afflicted by this disorder. The general age group affected is between 40 to 70 years. It is diagnosed with a biopsy. If found malignant, the melanoma nail tumor needs to be surgically removed.

References

Further Reading

Bump On The Nail: Causes & Treatment

The state of a person’s health is reflected by their fingernails. Conditions ranging from kidney disorders to thyroid disease can cause changes in the nails. A common change in the nails is the appearance of vertical or horizontal bumps on the nails. Although these bumps on the fingernails are mostly harmless, one still needs to know the underlying cause and get it treated to make their nails healthy, strong and pretty again. Have a bump on your nail? Go through the following article and know all about bump on thumb nail, causes and treatment.

Common Causes of Bump on Nails

Injury: Trauma to the nail or nail bed is the most common cause of bump on the nail.

Thyroid Disorders: Changes in thyroid medication dose and thyroid hormone blood levels can also affect the nail growth and lead to the development of these bumps on the thumb nail.

Skin Conditions: The living skin cells in the fingers create fingernails. So skin conditions like eczema and psoriasis can trigger the formation of bump or ridge on the nails too.

Skin Dryness: The bump on the nails can also form as a result of skin dryness. Even the deficiency of protein, vitamin A, zinc or calcium can cause fingernail ridges.

Serious Causes & Symptoms of Bump or Ridges on Nails

Vertical Bumps on Nails and Its Causes: Vertical ridges are furrows that start from the tip of the fingernail and run down to the cuticle. They are also termed as longitudinal striations or bands. Slight vertical ridges in fingernails mostly develop in older adults due to a slowing of cell turnover. This occurs when new skin cells produced under the surface of the skin rise up to replace the dead cells which are discarded from the surface. If other symptoms like changes in the colour or texture of the nails are experienced, then the nail ridges can be caused by a medical condition. In 20-nail dystrophy, or trachyonychia, the nail ridges can be accompanied by a change in nail colour, or increased roughness or brittleness of the nail. Vertical ridges along with certain visible changes in the nails which make them appear as concave or in the shape of a spoon can also be a sign of iron deficiency anaemia.

Horizontal Bumps on Nails with Causes: In majority of cases, deep horizontal ridges or Beau’s lines on the nails are symptoms of a serious condition. This condition literally stops any growth of nail till the time it is identified and treated. Thedre may also be chances of an Acute Kidney Disease playing a part more so if there are visible Beau’s lines on the nails. Moreover, if Beau’s lines appear on all the nails of the fingers and toes then it is a sign of a more threatening condition like diabetes, thyroid disease, syphilis, or mumps. Chemotherapy can also lead to Beau’s lines. Trauma to the nails can lead to the formation of brown or red spots under the nails. But if dark brown, black, or red colour changes appear under the nails without experiencing any nail trauma, it can be a sign of a serious condition, like melanoma or endocarditis.

Diagnosis of the Cause of Bump on the Nails

For nail damaged in an injury, one should let the affected nail and finger heal for a few weeks before deciding to visit a doctor. However, the individual should see doctor as soon as possible if the injury caused a crushed nail, ragged or clean cut through their nail, bleeding under the nail, or tearing of the nail. The doctor should also be consulted immediately when noticing any sudden serious changes in the nails. To diagnose the underlying cause of the nail bump or the nail ridge, the medical expert would first examine the nail and ask the patient about the symptoms they are experiencing. If kidney disease, nutritional deficiencies or diabetes are suspected to be causing the nail bump, urine and blood tests would be ordered to confirm the diagnosis. If a skin condition seems to be causing the ridges, a treatment plan can be started without any delay. However, if the doctor is unable to identify the cause of the nail ridges, a sample of the finger nail clippings may need to be analyzed for signs of infection.

Treatment of Bumps on Nails

Since bumps on the thumbnail and other fingernails are generally signs of other health issues, the treatment for these bumps or nail ridges depends on the underlying cause of the changes in the nails. For instance, ones who develop Beau’s lines due to diabetes can reduce the horizontal fingernail ridges simply by controlling their blood sugar.

Treatment for skin conditions like eczema includes application of moisturizers on the hands or topical ointments to decrease eczema symptoms and thus getting rid of the bump on the nails. For ridges caused due to deficiency of minerals or vitamins, making healthy dietary alterations and taking supplements to boost the nutrient levels can help to get rid of the bumps on the nails. The nail bumps can also be smoothened by buffing the fingernails with an emery board. However, the nails should never be pressed too hard to avoid any further damage. The advice of a dermatologist should also be taken on how to treat the nail with the bumps or ridges.

Prognosis of Bumps on Nails

Although fingernails ridges are generally a normal sign of aging, it is still very important to pay attention to them and other nail changes as these may be the first signs of a serious medical issue.

Also Read:

  • Types of Eyelid Bumps & Treatment to Get Rid of it
  • Causes of Heat Bumps & Home Remedies to Get Rid of it
  • Red Bumps on Baby: Causes, Symptoms, Treatment, Prognosis, Prevention
  • Are Bumps on Lower Lip Contagious?|Causes, Treatment, Home Remedies for Bumps on Lower Lip
  • 15 Useful Home Remedies To Get Rid Of Red Bumps On Legs
  • 12 Common Causes of Red Bumps on Legs & Treatments to Get Rid of Them
  • Bumps on the Skin after Scratching: Causes, Symptoms, Treatment, Prognosis, Prevention

Mucous Cysts of the Finger

Written by: Arthur M. Sharkey, M.D.

What is a Mucous Cyst?

Mucous cysts are small, fluid-filled sacs that form on the fingers and usually develop in patients 50 to 70 years of age. The mucous cyst usually appears at the joint nearest to the fingernail, called the distal interphalangeal (DIP) joint, and can be found on the thumb or on any of the other fingers. It presents as a small, sometimes painful, nodule in the DIP joint area. Most patients who develop a mucous cyst have wear and tear arthritis or osteoarthritis of the involved joint.

What causes a Mucous Cyst?

As the mucous cyst grows, it will often have a clear appearance due to the nature of the fluid-like material in your joints called synovial fluid. The mucous cyst occurs due to “kissing” osteophytes or bone spurs in the area of the DIP joints. This is related to osteoarthritis frequently present in these joints. The “kissing” osteophytes or bone spurs puncture the capsule of the joint, causing clear fluid from the joint surface to leak into the surrounding tissues. The tissues then form a hard capsule known as a cyst around this fluid. The cyst typically grows towards the area of the nail fold where nail plate growth occurs. Frequently, a nail deformity will form in the region of the mucous cyst due to it pressing on the nail matrix. A mucous cyst can often be directly visualized in the region due to thinning of the skin.

Diagnosis

An Orthopaedic hand specialist will first ask for a history of the problem and examine the patient’s fingers. An X-ray of the finger may be required to show degeneration related to osteoarthritis in the DIP joint area. This includes bone spurs and joint space narrowing. A patient may also have Heberden’s nodes, which are the bumps formed by osteophytes or bones spurs arising from in the finger.

Treatment Options for Mucous Cysts

Treatment for mucous cysts may either be nonsurgical or surgical. Nonsurgical treatment for mucous cysts includes observation by an Orthopaedic hand specialist. However, sometimes a mucous cyst will rupture. When a rupture occurs, it creates a path directly from the skin into the joint where bacteria can enter and cause a serious infection. For this reason, a mucous cyst should never be punctured at home due to the risk of contamination or infection of the joint area. Surgery is recommended if the patient feels significant pain or if the cyst and skin appear ready to rupture.

Surgical treatment typically requires outpatient surgical reconstruction with an excision (removal) of the cyst. This procedure involves a trimming and smoothing of the “kissing” osteophytes or bone spurs, so the capsule may heal surrounding the joint. If the skin on the finger is too closely attached to the cyst, a small piece of the skin may need to be removed from the finger. In this situation, a small skin graft is necessary. Surgery can usually be performed using regional anesthesia, meaning only the finger is numbed with lidocaine. The surgery lasts approximately one-half hour and is done as an outpatient procedure. The procedure has a relatively straightforward postoperative course.

Rehabilitation for Mucous Cyst Surgery

If a mucous cyst is surgically removed, a patient’s hand therapist will make a splint for the end of the
finger. The patient will then progress through range-of-motion exercises over a two week period. Other than some soreness in the area of the finger with pinch or grasp activity, healing is relatively straightforward. The sutures are removed approximately 10 days after surgery and normal activities are usually resumed two to three weeks after surgery.
Complications are rare but could include infection or progressive arthritis which can require a fusion of the joint. The nail deformity frequently resolves gradually with the treatment of the mucous cyst.

Dr. Arthur M. Sharkey is Board Certified in General Surgery as well as Plastic and Reconstructive Surgery with additional qualifications in Hand Surgery. Dr. Sharkey attended medical school at the University of Illinois, where he also completed his residency in General Surgery. He completed his residency in Plastic Surgery at St. Louis University, followed by fellowship training in Hand Surgery at Christine M. Kleinert Institute for Hand and Microsurgery in Louisville, KY.

Dr. Sharkey is an active member of the American Society for Plastic and Reconstructive Surgery.

Causes, Symptoms, Diagnosis & Treatment

Overview

What is a ganglion cyst?

A ganglion cyst (plural: ganglia) is a small, fluid-filled lump just below the skin. Ganglia usually form close to a joint. Most ganglion cysts are on the wrist, finger or foot.

How common are ganglion cysts?

Lots of people get ganglion cysts. Ganglia are some of the most common benign (noncancerous) masses that develop in the body’s soft tissues.

Symptoms and Causes

What causes ganglion cysts?

No one knows exactly what causes a ganglion cyst to start growing. Some theories indicate that a cyst may develop after something injures a joint, allowing tissue to leak or bulge out.

Currently, most researchers agree that ganglion cysts develop from mesenchymal cells at the synovial capsular junction as a result of the continuous micro-injury. Repetitive injury to the supporting capsular and ligamentous structures appears to stimulate fibroblasts to produce hyaluronic acid, which accumulates to produce the mucin “jelly-like” material commonly found in ganglion cysts

Who gets ganglion cysts?

From what the medical community understands about ganglion cysts, anyone can get them. Certain factors may increase your chances of having one of these cysts:

  • Sex: Women develop ganglia three times more often than men.
  • Age: For most people who develop a ganglion cyst, it appears in early to mid-adulthood, between 20 and 50.
  • Previous injury: Some healthcare providers believe a joint injury (such as tendonitis from overusing your wrist) could spur a ganglion cyst to develop in the future. Research hasn’t proven this theory yet.
  • Arthritis: Having arthritis in your hands makes it more likely you’ll get a ganglion cyst. People with arthritis often get a ganglion cyst near their fingertips (at the joint closest to the nail). But having a ganglion cyst on your finger does not mean you have (or will get) arthritis.

What are the symptoms of ganglion cysts?

A bump beneath the skin is the main sign of a ganglion cyst. This bump can vary in size and shape. It may grow larger over time or when you use that area (joint) more. The cyst may not bother you at all. If you do have symptoms, you may notice some muscle pain or a tingling sensation. This is usually mass effect, which means that the mass is causing pressure and may cause inflammation.

Where do ganglion cysts appear?

Ganglion cysts usually appear at specific joints. Using the joint near the cyst may increase swelling and worsen any discomfort you feel.

Ganglion cysts typically develop on the:

  • Wrist: On the front or back.
  • Finger: Near any finger joint (close to your palm or just below the fingernail).
  • Foot: Close to your ankle or near your toes.

What does a ganglion cyst look like?

A ganglion cyst usually looks like a lump or bump on your wrist, finger or foot. This lump may look symmetrical (round) or misshapen (more like an oval).

A ganglion cyst sits just below the skin’s surface. It may look like a bubble blown from a joint. Ganglia sometimes have a translucent effect (you can see through the lump at certain angles).

Are ganglion cysts hard or soft?

People experience ganglion cysts differently. Ganglia are usually (but not always) firm to the touch. Some people report that the fluid-filled cysts as soft. The lump likely moves easily under your skin.

Diagnosis and Tests

How is a ganglion cyst diagnosed?

Healthcare providers usually diagnose ganglia by physically examining you. A lump’s appearance and location (such as on the wrist or fingers) are telltale signs of ganglia. Your provider may press on the bump to see if it bothers you. Or they may shine a light on the lump to see if it’s translucent (partly see-through).

In some cases, your provider may remove a sample from inside the lump (called a biopsy) for further analysis. Ganglia usually contain a jellylike fluid, not solid tissue. In rare cases, your provider may recommend an X-ray to learn more about what’s causing your symptoms.

Your provider may use ultrasound to tell the difference between a solid mass and a cyst. There is also a difference between a ganglion cyst and a synovial cell. The difference is in the make-up of the lining of the cyst.

Can you have problems from a hidden ganglion cyst?

Some ganglion cysts are so small that they don’t cause obvious physical swelling, but they still cause pain. They are known as occult ganglions. Your healthcare provider may order a magnetic resonance imaging (MRI) test or an ultrasound to reveal them.

Management and Treatment

Do all ganglion cysts need to be treated?

If a ganglion cyst doesn’t bother you, it might not need treatment. Sometimes a ganglion cyst goes away on its own.

Your provider may recommend treatment if a ganglion cyst:

  • Hurts, which may happen when a cyst presses against a nerve or joint tissues.
  • Makes certain movements or tasks difficult, such as walking or gripping a pencil.
  • Makes you self-conscious about your appearance.

How are ganglion cysts treated

?

Ganglia cyst treatments include:

  • Anti-inflammatory medication may minimize swelling, easing mild levels of discomfort.
  • Splints or braces offer support and stop you from moving the affected area, reducing swelling and pain.
  • Aspiration is a procedure where your provider uses a needle to remove fluid from the cyst. Providers usually do aspiration in their office. You may feel better right away. Because this treatment only removes the fluid and not the entire cyst, your symptoms may return.

When does a ganglion cyst need surgery?

Your provider may consider surgery if other treatments don’t provide relief or your cyst comes back. Surgeons treat ganglia by removing the entire cyst. A cyst often includes a stalklike structure (root) attached to the cyst.

Your surgeon may use open (traditional) techniques or arthroscopy (tiny incisions). In some cases, surgeons may take some tissue from the nearby joint to fully repair the problem.

Surgery to remove a ganglion cyst is called ganglionectomy. It is usually an outpatient procedure. That means you should get to go home the day of surgery. Full recovery takes two to six weeks. [SD1] Orthopedic surgeons receive specialized training to perform intricate procedures on the body’s joints and other soft tissues.

Surgery may effectively resolve your symptoms. Having a ganglion cyst surgically removed greatly reduces the risk of a cyst coming back. Still, ganglia come back after surgery in an estimated 5% to 15% of cases.

Prevention

Can ganglion cysts be prevented?

You can’t prevent a ganglion cyst. Medical experts don’t know what causes them to develop.

Outlook / Prognosis

Are ganglion cysts dangerous?

Ganglion cysts are not dangerous. They are benign masses, which means they will not spread to other areas. Ganglion cysts are not cancer.

What is the prognosis (outlook) for people with ganglion cysts?

While some ganglion cysts may be painful, they pose no serious threat to your health.

Living With

What questions should I ask my healthcare provider?

If you have a ganglion cyst, you may want to ask your healthcare provider:

  • Do I need treatment right now?
  • Which treatment options do you recommend I try first, and why?
  • What are the chances a cyst will come back after treatment?
  • When would you consider surgery to treat ganglion cysts?
  • What are the risks and benefits of ganglionectomy surgery?

A note from Cleveland Clinic

If you have a ganglion cyst, you may not need treatment right away. If the lump doesn’t bother you, your provider may follow you over time to check for any concerning changes. Ganglion cysts are benign, which means these lumps aren’t cancer. They pose no long-term threat to your health. Many ganglion cysts go away on their own. If a ganglion cyst affects your quality of life in any way, ask your provider about treatment options. Splints, over-the-counter pain medication or surgery may provide relief.

Fingernail Bump | Congenital Hand and Arm Differences

As a hand surgeon, I am often asked questions about fingernails- whether related to irregularity (bumps, pain, swelling) of the nails or pain.  Most of these are minor or temporary issues and there are several excellent reviews on the internet including bundoo, medscape, and others.  Most of the issues on this list are infections including paronychia, felon, and herpetic whitlow.  This matches my experience with patients.

Paronychia of the thumb.  Note the redness suggestive of infection.

One somewhat less common anomaly is the osteochondroma (bone and cartilage growth) from the distal phalanx which appears beneath the nail.  This so- called subungual (meaning literally beneath the nail) osteochondroma is benign meaning it does not spread and typically does not come back when removed surgically.  I have previously blogged a number of times about osteochondromas– typically in the setting of multiple osteochondromatosis, a hereditary condition with osteochondromas in numerous areas throughout the body- see posts HERE, HERE, HERE, and HERE.    Osteochondromas beneath the fingernails may be associated with multiple osteochondromatosis or can be isolated without any other lesion.

Patients with a subungual osteochondroma complain about several issues.  First, the patient notice a deformity of the nail.  The reason for this nail change is that the layer above the bone receives pressure from the growing osteochondroma and the nail matrix (or nail bed) is altered.  When the nail matrix is changed, the nail becomes abnormal.  The second complaint may be a visible deformity of the nail with a bump.  And lastly, there may be pain but this is not always the primary complaint.

Basic nail anatomy. Photo from Wikipedia.

Importantly, this diagnosis overlaps with the subungual exostosis as described on Wikipedia.  In short, subungual osteochondromas are one type of exostosis but not all exostoses are osteochondromas.  Importantly, while I primarily see and treat these in the fingers, they more commonly happen affecting the toenails.

Wikipedia pictures of big toe with subungual exostosis.

Here is a case of a subungual osteochondroma of the index finger causing nail irregularity and pain.  Surgical treatment involves nail removal, excision of the osteochondroma, and repair of the nailbed. The nail grows back over time.

Subungual osteochondroma causing nail irregularity

Subungual osteochondroma causing nail irregularity

Subungual osteochondroma causing nail irregularity

x-ray of subungual osteochondroma causing nail irregularity.  Note the bump on the top of the distal phalanx (beneath nail which is not visible on the xray).

x-ray of subungual osteochondroma causing nail irregularity.  The osteochondroma is more difficult to see here.

Charles A. Goldfarb, MD
My Bio at Washington University
[email protected]

Subungual nodule of the great toe

Figure 1. Clinical appearance of the lesion located on the patient’s right great toe

Question 1

What is the most likely diagnosis?

Question 2

What is the aetiology of this condition?

Question 3

How is this condition diagnosed?

Question 4

What are the differential diagnoses?

Question 5

What is the appropriate management of this condition?

Answer 1

The most likely diagnosis is subungual exostosis (SE). Subungual exostosis is an uncommon, slow growing, benign osteocartilaginous tumour arising from the distal phalanx of a digit, beneath or adjacent to the nail bed. Dupuytren first described the condition in 1817.1,2

Answer 2

The precise aetiology of SE is unknown. It was previously considered to be a rare variant of osteochondroma. However, it is a reactive metaplasia of cartilage and is clinically, developmentally, radiographically and histologically distinct from osteochondroma.3 Associated factors such as trauma, chronic irritation to the bone and longstanding infection have been documented,1,2 however, chronic infection seems to be the result rather than the cause of this lesion.2

More recently, a balanced chromosomal translocation [involving t(X;6)] has been reported in a small series of patients with SE, which supports a neoplastic rather than a reactive process.4 In some cases, SE may be a manifestation of one of two inherited conditions: multiple exostoses syndrome and multiple exostoses-mental retardation syndrome (also called Langer-Giedion syndrome, trichorhinophalangeal syndrome type II, Alè-Calò syndrome or MEMR syndrome).5

Answer 3

Clinical appearance and radiographic findings are sufficient to confirm a diagnosis of SE. Clinically, SE appears as a firm and fixed subungual nodule that elevates the nail plate and produces distal or lateral onycholysis. Due to the pressure effect on the nail bed and plate, it tends to be painful and can result in nail plate deformity or destruction. Over time, ulceration and paronychial infection can occur. Although they can involve any digit, 70–80% of lesions are found on the great toe, usually on the dorsal or dorsomedial aspect of the distal phalanx. 

A higher frequency of SE is seen in children and young adults with a slight preponderance in girls and women.1,2,6 Subungual exostosis has characteristic radiographic features, and early use of radiography can prevent an incorrect diagnosis and inappropriate treatment, which can lead to recurrence or unnecessary amputation.1,2 An X-ray showing an exophytic lesion on the dorsal surface of the distal phalanx is diagnostic.2

Answer 4

Conditions to be considered in the differential diagnosis of SE are listed in Table 1.1,2,6 Most of these conditions can be easily differentiated from SE based on clinical features and/or X-ray findings. However, biopsy for histological examination may occasionally be necessary in order to establish the diagnosis.











Table 1. Conditions to consider in the differential diagnosis of subungual exostosis
Disease Differentiating features
Ingrown toenail (onychocryptosis) A painful, swollen, and tender toe, with crusting, purulent discharge, and friable or macerated granulation tissue at one or both sides of the nail bed
Verruca vulgaris (viral wart) Skin coloured or grayish plaque with a papillomatous, raised, thick and hyperkeratotic surface. Black dots (thrombosed superficial capillaries) may be present on the surface. Can originate from the nail folds or the hyponychium and spread to the nail bed. Onycholysis, onychodystrophy and/or pain may occur
Pyogenic granuloma Rapidly growing, exophytic papulonodule affecting the nail fold or hyponychium. Colour ranging from bright red to bluish-purple. Size may vary from millimetres to centimetres. May feature an ulcerated, erosive or friable surface, which bleeds easily
Glomus tumor Small red-bluish patch or nodule under the nail plate, usually on the fingernails and associated with paroxysmal pain, tenderness, and temperature sensitivity. Pain may be provoked by mild trauma and radiate to the limb. The nail may be ridged or dystrophic8
Osteochondroma Subungual location is quite rare. Well defined, firm, and often painful exophytic tumour causing onycholysis of the nail plate. Usually appears more proximal than a SE, and is often larger in size. Definitive diagnosis dependant on microscopic evaluation of the excised specimen (distinctive hyaline cartilage)3
Lipoma Extremely rare in the nail unit. May present as a soft, mobile, and usually asymptomatic nodular tumour, located subungually or in the lateral fold
Fibroma/fibrokeratoma Painless, slow growing, nodular or filiform (sausage-like) lesion, often with a keratotic surface, usually arising from beneath the proximal nail fold and causing a longitudinal depression. Subungual lesions are uncommon and usually result in onycholysis. Multiple periungual fibromas (Koenen tumors) can occur in patients with tuberous sclerosis8
Keratoacanthoma Rapidly growing, painful, well demarcated, dome-shaped nodule with a central keratin plug. If left, spontaneous involution occurs, leaving a small, pitted scar. May involve the hyponychium or the proximal nail fold and sometimes also affects the underlying bone. May be locally destructive. Difficult to distinguish from SCC and malignant transformation to SCC occurs rarely8,9
Squamous cell carcinoma (SCC) In situ SCC (Bowen disease): warty plaque, usually in fingernails; sometimes presents as periungual erythema associated with crusting, ulceration or fissuring, paronychia, longitudinal melanonychia or nail dystrophy8,10
SCC: slowly growing subungual nodule that eventually ulcerates and bleeds, or a wart-like periungual growth. The underlying bone is commonly involved. More common in the fingernails and after the fifth decade of life8,10
Subungual malignant melanoma Rare form of melanoma, most common in middle aged or elderly patients, especially on the thumb or hallux. May arise within the nail matrix or bed. Longitudinal melanonychia and Hutchinson sign (periungual brown-black pigmentation) are typical. Dermatoscopic examination is useful. Lesion is amelanotic in 25% of cases. May develop a usually painless nodule under the nail plate, with ulceration, bleeding and onycholysis8,11

Answer 5

Surgical excision is the appropriate management of this condition. The general practitioner can perform this in the clinic, but GPs unfamiliar with the procedure may prefer to refer to a general surgeon. Excision is usually performed under digital block anesthaesia. A conservative approach under the nail and preserving nail coverage is often possible. The skin is incised and the bony lesion dissected. It is then clipped off at its base using a bone rongeur or a strong nail clipper, followed by curettage of the distal phalanx with a bone curette. The wound is closed with simple sutures.

If the exostosis is located more proximally under the nail plate, the nail plate may need to be partially or totally avulsed to facilitate the entire removal of the lesion. A technique in which nail plate is sutured back into place after removal of the exostosis has also been described.4,6,7 Incomplete surgical resection may result in local recurrence. A recurrence rate of 5–11% has been reported.2 However, no case of malignant transformation has been reported.2,6

Case study follow up

Because of the degree of nail deformity and onycholysis, the patient required a complete nail plate resection. The tumour was removed and histology showed mature trabecular bone covered by hyaline fibrocartilage tissue, confirming the diagnosis of subungual exostosis.

Competing interests: None.
Provenance and peer review: Not commissioned; externally peer reviewed.

Nail Disorders in Children – FullText – Skin Appendage Disorders 2018, Vol. 4, No. 4

Abstract

Nail diseases in children do not account for a significant proportion of pediatric consultations, and most of the time the nails are not observed by the clinician, overlooking their importance. Specific examination of the nails is neglected, while localization to the nails could be an initial sign of a syndrome or a systemic disorder. Nail diseases in the pediatric population differ from those in adults in terms of diagnostic approach and management; some of them even are manifested mainly or exclusively in children. Pediatric patients with underlying systemic disorders are more likely to manifest acquired disorders of the nails. Although rare, nail diseases in children are a source of anxiety for the parents. Examination of the nails is an essential part of pediatric physical examination. A correct clinical history and careful examination help the clinician to distinguish the different conditions and to decide on the correct management of nail diseases in young patients. A classification of nail dystrophies according to age is somewhat arbitrary and a unique classification does not exist. Nail diseases in the pediatric population can be divided according to age groups where a predilection appears in most of the cases. Moreover, certain abnormalities may be lifelong once acquired, but their presentation may be modified by age, worsening or improving during life. This review describes many of the nail conditions that are seen in the pediatric population aging from newborn to toddler, starting with physiological aspects to better recognize the pathological conditions.

© 2018 S. Karger AG, Basel


Introduction

The occurrence of nail diseases in infants and children is uncommon. Ethnic, socioeconomic, and environmental factors influence their incidence. Most publications regarding nail diseases refer to single cases of rare inherited disorders. Only a few papers have described pediatric nail alterations, especially in newborns [1].

Understanding nail anatomy should enable a clinician to interpret nail signs with greater clarity and to better understand and manage nail diseases. This is especially true with children, where the small size of the nail makes it more difficult to diagnose and manage [2]. The nails of newborns (Fig. 1) are thin and soft, and the nail growth rate in children is similar to the values observed in young adults, the fastest values of nail growth (1.5 mm per day) being reached between the ages of 10 and 14 years (Fig. 2). The thickness and breadth of the nail plate increase rapidly in the first two decades of life.

Fig. 1.

a, b Normal fingernails of a 3-day-old child.

Fig. 2.

Normal fingernails (a) and toenails (b) of a 5-year-old child.

Pediatric patients have a unique susceptibility to nail disorders. Children are more susceptible to bacterial and viral diseases; yet, they are less likely to experience fungal infection of the nail apparatus. Although the acquired nail conditions observed in childhood are similar to those of adults, the prevalence of several diseases may vary in the different age groups. Infections and inflammatory diseases account for a high proportion of consultations. Instead, hereditary or autoimmune conditions are commonly observed and diagnosed in children.

This exhaustive review is organized into categories that are based on the age at presentation at which pediatric patients most frequently have typical manifestations for a diagnosis and the disease manifestations during the different ages. The authors also demonstrate how nail abnormalities can be a useful marker of specific systemic pathologies.

Epidemiology

Nail diseases may be congenital or hereditary, and signs are present at birth or may be acquired and appear later during the life of a child. Nail abnormalities are a feature of many genodermatoses. One report suggests that about 75% of congenital syndromes are associated with nail abnormalities [3].

The exact prevalence of nail conditions in the pediatric population is unknown, but the literature estimates a variable rate from 3 to 11% [4]. The prevalence of nail alterations was 11 and 6.8% in two pediatric studies of 100 and 250 children, respectively, seen in pediatric and dermatologic departments [1]. The number of reports about nail diseases in children is relatively small, and the epidemiological data vary, but a rise in prevalence has been demonstrated. However, only a small amount of epidemiological data extracted from a few studies is currently available for the pediatric population [5].

Classification

Congenital and hereditary nail diseases include a number of conditions in which nail abnormalities are present at birth or develop during infancy. In some cases, nail abnormalities are key features for the diagnosis of syndromes or hereditary diseases.

Nail disorders in children can be divided into different categories. A way to classify pediatric nail disorders is according to the age at which they appear in most of the cases, focusing on diseases that affect young patients from birth to 5 years of life (Table 1). Every category is then divided into (1) physiological alterations, representing particular nail features typical of children that usually disappear with aging and do not require any treatment, or only to reassure parents, and (2) pathological conditions.

Table 1.

Classification of nail diseases in pediatric patients from birth to 5 years of age

The first category consists of newborns, with alterations present at birth or in the first days of life. The second category is represented by infants from the age of 1 month to 1 year. Children 1–3 years old, i.e., toddlers, represent the third category, and, finally, the last category is characterized by children between 3 and 5 years of age, named preschoolers.

Newborns: At Birth

Physiological Alterations

Koilonychia

Koilonychia describes nails with a transverse and/or longitudinal concave nail dystrophy with a central depression (Fig. 3). The term “spoon nails” describes the flattening in the middle with an everted lateral edge. It has multiple etiologies: hereditary, acquired, or idiopathic. It is frequently idiopathic in newborns – especially on the big toe, where it is present in 33% of cases as a normal variant – and spontaneously regresses when the nail plate thickens after the age of 9 years. It may be a manifestation of inflammatory skin diseases such as psoriasis or lichen planus, or secondary to systemic alterations such as iron deficiency, Plummer-Vinson syndrome, nutritional store abnormalities, or endocrine disorders [6].

Fig. 3.

Koilonychia in anterior (a) and lateral view (b).

Transient Physiological Onychoschizia

Transient physiological onychoschizia is mainly noted on the big toes and thumbs, with transverse and lamellar splitting at the free edge in early infancy (Fig. 4) in 28.8% of newborns [6, 7]. This apparent hypertrophy does not need any treatment, because it is probably a physiologically transitory alteration.

Fig. 4.

Clinical picture (a) and dermoscopy (b) of transient physiological onychoschizia.

Traumatic Punctate Leukonychia

Because of the smooth surface of the nail plate in newborns, it is possible to observe the presence of punctate leukonychia. This is a true leukonychia caused by alterations or imperfections in the proximal part of the matrix [8].

Apparent Hypertrophy of the Proximal and Lateral Nail Fold: “Pseudo-Hypertrophy” of the Hallux

This is present in 73.1% of newborns and accentuated by the presence of koilonychia and a triangular shape of the nail plate [1]. The thin nail plate and the shape induce a minor force pushing down the lateral folds, which react by overlapping but with no sign of inflammation.

Pathological Conditions

Clubbing

Usually, the angle between the proximal nail fold and the nail plate is named Lovibond’s angle, and it is greater than 180°. When there is an alteration to this angle, the nails are affected by clubbing, where the nail resembles a clock glass with hypercurvature in the transversal and longitudinal axes.

Clubbing may be congenital or acquired. Acquired clubbing is uncommon, and in 80% of cases is associated with pulmonary diseases. Congenital clubbing can be associated with cardiac disorders, or more commonly lung or bowel disease [9]. Sometimes, at birth, the nail curves over the tip of the digit towards the pulp; physiological clubbing may be seen in this age group.

Nail-Patella Syndrome

Nail-patella syndrome is a rare autosomal dominant disorder with variable expressivity caused by mutations in the LMX1B gene, located in chromosome 9q34, with an incidence of approximately 1: 50,000, with de novo mutations accounting for 12.5% of cases. A clinical tetrad of changes to the nails, knees, and elbows, as well as the presence of iliac horns, is typical [10].

Nail anomalies are evident at birth in 95.1% of nail-patella syndrome patients, and are described as micronychia or anonychia, with thin or absent plates, increased fragility, Beau’s lines, longitudinal ridging, and triangular lunulae, which are the most common and pathognomonic finding. The severity of the signs is variable, and there is phenotypic variability. Early diagnosis is necessary for the management of the disease.

The characteristic finding regarding lunulae is characterized by their triangular shape, with the horizontal basis of the triangle level with the proximal margin and the point of the triangle directed toward the distal margin. Nail changes can be seen in the fingernails, and are commonly bilateral and symmetrical, with their severity decreasing from the 1st towards the little finger.

Iliac horns, protuberances arising from the central part of the external iliac fossae, are pathognomonic radiological findings, and are evident also on prenatal ultrasonography [11]. Renal damage with proteinuria, hema­turia, hypertension, and nephrotic syndrome [12] is the most severe complication.

Multiple Ingrown Fingernails in Newborns

Multiple ingrown fingernails in newborns are possible around the 6th day of life due to a grasp reflex, as well as distal toenail embedding with a normally directed nail, due to a short and thin nail plate. During infancy, the distal phalanx has not yet ossified, and thus pressure to the nail plate can cause it to embed in the surrounding soft tissue. As the innate immune system recognizes the embedded nail plate as a foreign body causing an inflammatory reaction, the infant’s grasp reflex can cause the necessary pressure to the nail plate to start this condition.

It is a benign condition with spontaneous regression as the reflex disappears around the 4th month of life, and the condition does not recur [13]. It is transitory unless there is congenital malalignment.

Infants: From 1 Month to 1 Year of Age

Physiological Alterations

Transient Light-Brown or Ochre Pigmentation of the Proximal Nail Fold

Transient light-brown or ochre pigmentation of the proximal nail fold and dorsal digit to the interphalangeal joint is more typical of dark-skinned infants. It is a physiological melanic pigmentation appearing in the first 6 months of life and persists for a few months, characterized by a regular reticular pattern located only in the periungual tissue without involvement of the cuticle or nail unit [9]. This condition is benign and transitory, and no symptoms are associated with it.

Beau’s Lines of the Fingernails

Beau’s lines of the fingernails appear at 4 weeks of life in 92% of newborns and disappear with growth before 14 weeks. This phenomenon describes a single transverse depression of the fingernails (Fig. 5). Beau’s lines result from intrauterine distress or physiological alterations during birth [7]. They are transverse nail plate surface depressions resulting from mild trauma to the proximal nail matrix, with transiently reduced nail growth.

Fig. 5.

Clinical picture (a) and dermoscopy (b) of a Beau’s line in a newborn.

Pathological Conditions

Ectodermal Dysplasias

Ectodermal dysplasias are a complex group of congenital disorders that includes 170–200 distinct conditions, characterized by abnormal development in two or more ectodermal structures (hair, nails, teeth, and sweat glands).

According to Visinoni et al. [14], a molecular basis was identified in only 30% of cases. Nail alterations are not specific, and they include hypoplasia with subungual hyperkeratosis in most cases (Fig. 6), or anonychia or micronychia, thinning, or onycholysis.

Fig. 6.

Toddlers: From 1 to 3 Years of Age

Physiological Alterations

Physiological alterations in toddlers are typically due to simple traumata that induce an inflammation of the nail matrix, and they reflect superficial alterations to the nail plate. These events are typical of this age group, because toddlers play continually with their hands.

Punctate Leukonychia

Children usually are affected by true leukonychia that occurs due to trauma to the distal matrix. In true leukonychia, the milky white discoloration is located within the nail plate, and results from the presence of foci of parakeratotic cells within the nail plate. The presence of nuclei impairs nail plate transparency and reflects light, resulting in the white color. Depending on its shape, leukonychia can be punctate or transverse. Punctate leukonychia is typical of several fingernails (Fig. 7). Transverse leukonychia is quite rare in children, and is typically restricted to the 1st toenails. This variety of true leukonychia is due to trauma from shoes to a thick nail plate, which transmits the trauma to the distal nail matrix, resulting in periodic defective keratinization with the production of one or more transverse white bands that move distally with nail growth [15].

Fig. 7.

Punctate leukonychia in the fingernails.

Pitting

Pits are small depressions of the nail plate surface. Depending on its size and distribution, pitting may be diagnostic of a specific disease (Fig. 8a). Dermoscopy of pitting is very helpful to distinguish diseases appearing with pitting, especially in cases where pitting is the only sign (Fig. 8b) [16]. Pitting is commonly seen in nail psoriasis and in nails of patients with alopecia areata. The pits of psoriasis are large, deep, and irregular in shape, size, and distribution, while the pits of alopecia areata are regular in shape, size, and distribution.

Fig. 8.

Clinical picture (a) and dermoscopy (b) of pitting.

Pathological Conditions

Dyskeratosis Congenita

Dyskeratosis congenita is a very rare hereditary disorder of telomere maintenance that causes short telomeres and may demonstrate different patterns of inheritance [17]. Dystrophy of the nails, leukokeratosis of the oral mucosa, and extensive net-like pigmentation of the skin is the typical triad of symptoms. Nail changes are the first manifestation, appearing during early childhood, sometimes as early as the 1st year of life, and they lead to splitting, dystrophy, and shedding of nails.

Multisystemic involvement (dental, gastrointestinal, genitourinary, neurological, ophthalmic, pulmonary, and skeletal) has been described, and bone marrow failure can develop in 50–90% of cases [2].

Epidermolysis Bullosa

Epidermolysis bullosa (EB) is a group of genetic disorders with an autosomal dominant or recessive mode of inheritance and more than 300 mutations in genes encoding different proteins involved mainly in the structure and function of the dermal-epidermal junction [18].

A marked mechanical fragility of epithelial tissues is the most important feature, with nonscarring blistering and erosions after minor trauma due to anchoring defects between the epidermis and dermis, and it has several, varying phenotypes. The variation in phenotypic expression depends on the involved structural protein that mediates cell adherence between the different layers of the skin.

EB is classified by level of skin cleavage (from top to bottom) into four groups: (1) EB simplex, (2) junctional EB, (3) dystrophic EB, and (4) Kindler syndrome. The disease can involve the eyes, nose, ears, upper airways, genitourinary tract, and gastrointestinal tract.

The phenotypes for every subtype range from relatively mild blistering of the fingernails and toenails to more generalized blistering. Nail abnormalities usually precede skin blistering. Blisters are rarely present or minimal at birth, and they may occur at approximately the age of 18 months; some individuals manifest the disease in adolescence or early adulthood.

The nail dystrophy can be permanent, with anonychia, progressive hyperkeratosis with onychogryphosis, nail thickening, and parrot beak nail deformity in adult life [19].

Congenital Malalignment of the Hallux

In congenital malalignment of the great toenail, the matrix is laterally deviated and not parallel to the corresponding axis of the distal phalanx, which is why it produces a short dystrophic nail (Fig. 9) [20]. This deviation frequently causes periungual inflammation, onychogryphosis, and alterations to the nail plate, with ridging due to trauma to the position of the toenail. Spontaneous improvement is possible with a good nail bed attachment and persistence only of a malaligned appearance. When there is no improvement by the age of 2 years, the nail stays thick, triangular, medially bent, discolored, and oystershell-like with severe onycholysis. A surgical approach is recommended in severe cases [21].

Fig. 9.

Congenital malalignment of the great toenails.

Congenital Hypertrophy of the Lateral Nail Folds

The medial and/or lateral nail folds are hypertrophic and cover up to one-half of the nail partially or completely (Fig. 10). Congenital hypertrophy of the lateral nail folds is present at birth or shortly thereafter due to asynchronism between the growth of the nail plate and that of the soft tissues [4]. Possible complications due to hypertrophy of the folds are painful paronychia, koilonychias, and malalignment of the same digit. Spontaneous improvement may occur over time within the 1st year of life. If no improvement is evident after this period, surgery is a possible option to consider [21].

Fig. 10.

Congenital hypertrophy of the lateral nail folds.

Vertical Implantation of the Nail of the 5th Toe

Vertical implantation of the nail of the 5th toe is an uncommon disorder that consists of a lateral implantation of the 5th toe matrix. The nail virtually grows in a vertical direction, and bends backwards with great discomfort especially when socks are pulled on. In addition, it creates an aesthetic inconvenience [7]. Keeping the nail extremely short usually suffices to solve the inconvenience of the condition, but a possible option is complete nail ablation with phenolization [4].

Curved Nail of the 4th Toe

Curved nail of the 4th toe is mostly described in young Japanese patients, where the 4th digit, usually bilaterally, is curved without any bone or soft tissue alteration. It is a congenital condition inherited as an autosomal recessive trait [7]. No explanation is described for this condition. It has no clinical significance and is not associated with any syndrome. Although it is congenital, usually it is noted after birth because of the deformity of hypoplasia of the distal phalanx [4].

Anonychia and Micronychia

Anonychia and micronychia can be isolated or part of several complex syndromes – such as Iso-Kikuchi syndrome, ectodermal dysplasia, and nail-patella syndrome – or in utero exposure to toxins. The term anonychia describes either partial or complete absence of the nail (Fig. 11). It can be congenital and associated with other deformities describing an autosomal or recessive inheritance. However, it can also be acquired after a great event inducing the complete destruction of the affected area, such as blisters in EB [19] or inflammation in nail lichen planus. The term micronychia identifies a congenital malformation with hypoplasia of the nail plate. It can be secondary to exposure to teratogenic drugs in early pregnancy or part of a syndrome [7].

Fig. 11.

Congenital anonychia in a 1-year-old child.

Beau’s Lines and Onychomadesis

Trauma or infection, with substantial matrix inflammation or damage, results in a wave of thinned nail in the form of a transverse groove (Beau’s line) growing out at a rate that allows calculation of the time since the episode occurred. An event within a digit will limit the feature to that digit. A generalized event, such as systemic illness, may create a groove in multiple digits. When the underlying event is great, a detachment of the nail plate from the proximal nail fold results in a full-thickness transverse interruption of the nail plate, followed by shedding of the nail, known as onychomadesis.

Drug eruptions as well as systemic infections are considered trigger factors for the onset of onychomadesis [22].

Finger Sucking

Frequently, infants suck one finger, usually a thumb, even during the visit to the doctor. Thumb-sucking is a common childhood habit that may increase microbial exposure. Thirty-one percent of children are frequent thumb-suckers at more than 1 year of age [23]. The prolonged exposure of the skin of the digit to saliva induces maceration and irritation, with contact dermatitis of the periungual tissue causing cuticle damage and paronychia. The inflamed periungual skin displays skin maceration crusts and scaling, and it possibly induces damage to the nail matrix with the presence of Beau’s lines that describe a longitudinal furrow across the nail plate with nail growth. Another possibility is the habit of pushing back the cuticle, which induces surface abnormalities (washboard nails).

One or more bands of longitudinal melanonychia can appear due to melanocytic activation after these types of trauma to the nail matrix. Periungual warts and bacterial paronychia are common infective complications that require a specific local therapy.

Hand, Foot, and Mouth Disease

One of the most studied infections is hand, foot, and mouth disease, where the relationship with onychomadesis is well described [24]. Onychomadesis of several or all nails occurs 1–2 months after the acute infection (Fig. 12). This is a common pediatric viral infection with vesicular eruptions that involve the palms, soles, and oral cavity. Nail shedding starts to present without pain or inflammation until complete separation of the nail plate in transversal ridging of several or all fingernails and toenails. This condition is reversible and self-limited, but the exact mechanism by which the illness induces this damage to the matrix is unknown. No specific treatment is required, only to reassure the family.

Fig. 12.

Onychomadesis in the fingernails due to hand, foot, and mouth disease.

Preschoolers: From 3 to 5 Years of Age

Physiological Alterations

Chevron or Herringbone Nails

In chevron or herringbone nails, the nail plate surface shows oblique and longitudinal diagonal ridges converging towards the center of the nail plate at the distal part, describing a central spine with the appearance of a V-shape or a chevron. It appears between the age of 5 and 7 years and disappears in early adulthood [25]. It affects several or all fingernails, with an undetermined etiology [4].

Pathological Conditions

Pachyonychia Congenita

Pachyonychia congenita is an uncommon genodermatosis characterized by defective keratinization. Clinical features include hypertrophic nail dystrophy, painful palmoplantar blisters, cysts, follicular hyperkeratosis, and oral leukokeratosis. The International Pachyonychia Congenita Research Registry (IPCRR) has identified more than 100 mutations [26]. Its inheritance is autosomal dominant, but sporadic and autosomal recessive cases are reported [27]. There are two types of pachyonychia congenita: type 1, also known as Jadassohn-Lewandowsky syndrome, and type 2, also known as Jackson-Lawler syndrome; they are linked to mutations in genes encoding five differentiation-specific keratins: 6A, 6B, 6C, 16, and 17.

Early development of nail thickening with an increased curvature due to nail bed hyperkeratosis, associated with palmoplantar keratoderma, is the clinical manifestation. Nail and skin changes are present at birth in only 50% of cases, but by 5 years, they are seen in more than 75% of children. By the age of 10 years, pain can be present as a symptom, which greatly impairs quality of life [28].

Acute Paronychia

Cuticle loss makes it more difficult for the proximal nail fold to play its protective role and means that the first seal is broken. Acute paronychia is a painful bacterial or viral infection resulting from a break in the skin, a prick of a thorn, or a splinter (Fig. 13). The most likely pathogens include bacteria, such as Staphylococcus aureus and β-hemolytic Streptococcus [29]. After the infection, an inflammatory response ensues in the digit, with resultant swelling, erythema, tenderness, and secondary pus formation [4]. As the nail matrix in children is particularly fragile, even a mild acute paronychia may induce permanent nail dystrophy.

Fig. 13.

Acute paronychia due to bacterial injury.

Chronic manipulation, inflammation, or infection can result in chronic absence of the cuticle, i.e., chronic paronychia, often presenting with acute flares over a long period of time [30]. Possible therapies include compression primarily and local medication with antibiotic cream secondarily. In case of a strong reaction, possible drainage is advised and specific systemic antibiotic or antiviral therapy has to be started.

Bacterial Diseases

Blistering Distal Dactylitis

Blistering distal dactylitis is a rare, localized infection by gram-positive bacteria that most commonly affects children. It is characterized by development of an acral oval fluid-filled bulla, 10–30 mm in diameter, usually on one finger pad [31]. The age group affected is 2–16 years old. The bulla can evolve into erosions over the course of several days. The causative organism is group A β-hemolytic Streptococcus; less commonly, Staphylococcus aureus and Staphylococcus epidermis are isolated. A differential diagnosis includes herpetic whitlow, EB, bullous impetigo, and friction blisters. Culture is necessary for a differential diagnosis and to identify the organism for the choice of treatment. The optimal treatment for these patients is incision and drainage, warm compresses, and oral antibiotics [4].

Viral Diseases

Herpes Simplex

Herpes simplex infection, both primary and secondary, may localize to one finger. Secondary fingernail herpes simplex virus infections are presenting as a recurrent paronychia in the same digit, characterized by grouped vesicles located on the lateral nail fold accompanied with pain, swelling, and erythema. Rarely, a nail bed location may occur, with painful lateral onycholysis and sub­ungual hemorrhage. The diagnosis is confirmed with a Tzanck smear or viral culture, and specific antiviral therapy is recommended, usually with local application.

Ungual Warts

Viral warts are benign infectious lesions due to human papillomavirus strains of various types. They are very common in children over 6 years of age, facilitated by nail biting. Clinically, warts start as small round hyperkeratotic masses with a rough surface; then they grow, reaching a size of up to 10–20 mm and induce fissuring with possible pain. They are usually located in the proximal nail folds but may also develop under the nail plate with onycholysis. It is recommended that the onycholytic part be cut when it is present and the warts be treated with keratolytic cream such as urea or salicylic acid.

Trachyonychia

Trachyonychia, or twenty-nail dystrophy (TND), means nail roughness. This is a benign inflammatory nail condition of the proximal nail matrix. It can be present at any age, but the mean age at appearance is 2.7 years (range 2–7) [32]. Its incidence in the pediatric population is unknown. Clinically, it can be divided into two main groups: idiopathic TND and TND associated with other dermatological diseases including alopecia areata, lichen planus, eczema, and psoriasis. Trachyonychia is not a distinctive disease but only the clinical result of disorders that involve the nail matrix [22]. In the absence of anamnestic or clinical data that suggest its pathology, it is impossible to detect a disease that is causing the trachyonychia without histopathological study [32]. Nail biopsy is not recommended for diagnosis, due to the benignity of the disease and a good prognosis. TND can affect one nail or all nails (Fig. 14). The affected nails show a diffuse roughness with longitudinal and regular fissuring, and are usually opaque with a sandpaper appearance. Nail thinning with koilonychia and cuticle hyperkeratosis may be present. TND will show spontaneous improvement over time.

Fig. 14.

Trachyonychia of all digits (twenty-nail dystrophy).

Nail Lichen Striatus

Nail lichen striatus is rare and almost exclusively seen in children. Clinically, one nail is involved, which shows lichenoid abnormalities with longitudinal ridging restricted to its medial or lateral portion (Fig. 15). It usually continues with linear skin lesions characterized by papules or verrucous scales along Blaschko’s lines. Nail involvement appears a few weeks after the initial skin lesions. Nail changes may occasionally be the only clinical sign, and they are typically limited to one portion of the nail and include findings such as longitudinal fissuring, onycholysis, and distal splitting [33]. The condition is asymptomatic and self-limiting and should be suspected when a child presents lichen planus-like abnormalities in a single nail. Local steroids are suggested as treatment.

Fig. 15.

Clinical picture (a) and dermoscopy (b) of nail lichen striatus of the 1st digit.

Longitudinal Melanonychia

Longitudinal melanonychia is a brown-black pigmented band from the proximal to the distal nail plate due to the presence of melanin within the nail plate. The pigmentation is produced by activation or proliferation of quiescent melanocytes. Unlike in adults, the principal cause of longitudinal melanonychia in children is nail matrix nevi, and it may be present at birth or may develop at 2–4 years of age (Fig. 16a). In children, 75% of cases of longitudinal melanonychia are due to benign melanocytic hyperplasia, mainly junctional nevi, and 25% are due to melanocytic activation [34]. The clinical and dermoscopic parameters used for adults are not valid for children (Fig. 16b) [35]. Nail melanoma in children is extremely rare, and exceptional in Caucasians [36]. A clinical and dermoscopic sign that suggests melanoma in children is rapid evolution in growth and color, which requires surgical excision.

Fig. 16.

Clinical picture (a) and dermoscopy (b) of longitudinal melanonychia due to a nail matrix nevus.

Conclusion

Nails of newborns are thin and soft, and they frequently present with physiological alterations that are not necessary to treat but only need a wait-and-see approach and reassurance of the parents. Obviously, follow-up of patients is important to be sure that these physiological conditions do not become pathological conditions that require therapy. Furthermore, several conditions may lead to dystrophy of the nails, including acquired conditions such as trauma, trachyonychia, or lichen striatus and congenital disorders. Hereditary or autoimmune conditions are commonly observed and diagnosed in children. Rarely, nail signs are the first manifestation of a genetic disorder, and in this case it is usually associated with other skin or mucosal involvement. It is important to highlight the importance of nail examination in children in order to perform early diagnoses and to identify and treat complications. A correct clinical history and careful examination help the clinician to distinguish between different conditions and to decide on the correct management of nail diseases in young patients. The changes are influenced by habits and environmental factors, which again are influenced by the age of the patient. This review provided a comprehensive review of prevalent nail diseases in a pediatric patient cohort, especially from birth to preschool age.

Disclosure Statement

The authors declare no conflict of interest. The authors declare they had no funding sources supporting this work.

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  26. O’Toole ED, Kaspar RL, Sprecher E, Schwartz ME, Rittié L: Pachyonychia congenita cornered: report on the 11th Annual Interna tional Pachyonychia Congenita Consortium Meeting. Br J Dermatol 2014; 171: 974–977.


  27. Forrest CE, Casey G, Mordaunt DA, Thompson EM, Gordon L: Pachyonychia congenita: a spectrum of KRT6a mutations in Australian patients. Pediatr Dermatol 2016; 33: 337–342.


  28. Piraccini BM, Starace M: Nail disorders in infant and children. Curr Opin Pediatr 2014; 26: 440–445.


  29. Rigopoulos D, Larios G, Gregoriou S, Alevizos A: Acute and chronic paronychia. Am Fam Physician 2008; 77: 339–346.


  30. Tosti A, Peluso AM, Piraccini BM: Nail diseases in children. Adv Dermatol 1997; 13: 353–373.


  31. Cohen R, Levy C, Cohen J, Corrard F, Deberdt P, Béchet S, Bonacorsi S, Bidet P: Diagnostic of group A streptococcal blistering distal dactylitis (in French). Arch Pediatr 2014; 21(suppl 2):S93–S96.


  32. Kumar MG, Ciliberto H, Bayliss SJ: Long-term follow up of pediatric trachyonychia. Pediatr Dermatol 2015; 32: 198–200.


  33. Kim M, Jung HJ, Eun YS, Cho BK, Park HJ: Nail lichen striatus: report of seven cases and review of the literature. Int J Dermatol 2015; 54: 1255–1260.


  34. Goettmann-Bonvallott S, André J, Belaich S: Longitudinal melanonychia in children: a clinical and histopathologic study of 40 cases. J Am Acad Dermatol 1999; 41: 17–22.


  35. Tosti A, Baran R, Piraccini BM, Cameli N, Fanti PA: Nail matrix nevi: a clinical and histopathologic study of twenty-two patients. J Am Acad Dermatol 1996; 34(pt 1):765–771.


  36. Tosti A, Piraccini BM, Cagalli A, Haneke E: In situ melanoma of the nail unit in children: report of two cases in fair-skinned Caucasian children. Pediatr Dermatol 2012; 29: 79–83.

Author Contacts

Michela Starace

Dermatology, Department of Experimental, Diagnostic and Specialty Medicine

University of Bologna, V. Massarenti 1

IT–40138 Bologna (Italy)

E-Mail [email protected]


Article / Publication Details

First-Page Preview


Received: November 13, 2017
Accepted: December 05, 2017
Published online: January 23, 2018

Issue release date: October 2018


Number of Print Pages: 13

Number of Figures: 16

Number of Tables: 1


ISSN: 2296-9195 (Print)
eISSN: 2296-9160 (Online)


For additional information: https://www.karger.com/SAD


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Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.

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Red bump above the nail – Question to the surgeon

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Hallux valgus

Painful feet and deformity of the big toe

The journey from shoe store to foot surgeon can be shorter than expected, especially for women who like to wear high heels often and for extended periods.High heels contribute Hallux valgus , which leads to pain and deformities of the other toes. However, for over 100 years, it has been difficult to imagine women’s fashion without heels. High heels visually make the legs longer, lift petite ladies a few centimeters up, make them slimmer and give the legs more attractive outlines. In addition, women in heels look more attractive.

These or similar arguments explain the motivation of millions of women to wear high-heeled shoes over and over again, even though their feet are severely affected.In addition to the obvious risk of tripping, getting caught in the heel, spraining the ankle, women who wear high-heeled shoes too often and for too long, especially ladies with clubfoot and hereditary connective tissue weakness, are at additional risk – the risk of acquiring hallux valgus.

What is hallux valgus

Hallux valgus, also known as a “bump” or “bunion,” is a displacement of the first metatarsal bone toward the inner edge of the foot.This widens the metatarsal area (transverse flat feet). However, the adductor tendon has no ability to stretch and pulls the big toe towards the outer edge of the foot. As a result, the free part of the toe deviates to the outer edge of the foot, and its base with the head of the 1st metatarsal bone is displaced inward.

This deformation is widespread. Approximately one in ten people suffers from a deformity of the forefoot of one degree or another. 1

Risk factors and causes of hallux valgus

Hallux valgus is a cumulative result of congenital connective tissue weakness and abnormal biomechanics (eg, prolonged high-heeled walking).In the initial stage, curvature is usually only a cosmetic problem. The pain appears using narrow shoes already in the presence of deformation, which is the cause of bursitis.

Flat feet

Flat feet is a risk factor, and also provokes the rapid progression of the disease, because the flattening of the transverse arch increases the transverse size of the foot.As a result, the shoes become narrow, which is the cause of chronic bursitis.

Wrong shoes

The use of high-heeled footwear is a powerful risk factor as it contributes to the onset and progression of deformity. The fact is that the heels “turn off” the shock-absorbing function of the foot, and almost all body weight presses on the first metatarsal bone. Too narrow footwear in the presence of deformation contributes to the aggravation of pain syndrome, since it constantly presses on the protruding bone.

Overweight

Large body mass also contributes to the development of deformity.

Heredity

Heredity is a so-called unmodifiable risk factor, because we cannot change it. With the inheritance of the weakness of the connective tissue, the likelihood of developing hallux valgus increases sharply.People with a congenital predisposition should take special care of their legs and exclude the influence of other risk factors as much as possible, because their musculoskeletal system is especially sensitive to the influence of negative factors.

Development of deformity in childhood

Some children aged 12 and over already have a deformity of the big toe. It usually occurs with a hereditary predisposition and / or a gross violation of biomechanics during the formation of the foot.An example of a gross violation of biomechanics is ballet.

Symptoms of hallux valgus

  • Pain, redness and swelling at the base of the big toe are the main symptoms, the severity of which varies greatly from patient to patient. Even a slight deformity can cause severe pain in some people, while in others there is almost no pain, despite the very pronounced deformity.
  • Pain in the middle of the foot. As the deformity progresses, the so-called first ray (thumb and first metatarsal bone) becomes unstable, which leads to a change in biomechanics in general. The load is distributed to the midfoot, which is sometimes able to support it. The result is pain.
  • Hammer toe. Thumb drift in tight shoes leaves no room for other toes. As a result, one or more fingers move upward.With prolonged stay in this position, contracture of the tendon of the finger occurs and hammer-like deformation occurs.
  • Oteoarthrosis: the deformity contributes to the destruction of the articular cartilage, which leads to the development of osteoarthritis of the metatarsophalangeal joint of the first toe.

Hallux valgus treatment

The resulting deformity cannot be cured by conservative methods. At the initial visit , the doctor must decide which treatment is suitable in this situation.At the same time, the doctor takes into account many factors, including the severity of the deformity, the intensity of the pain, and the patient’s concomitant diseases.

  • Insoles, splints, bungee. If the thumb can be returned to its original position (flexible deformity), then orthotics will be quite effective. The insoles can restore the lateral arch and reduce the flatness of the foot, which will relieve the pressure of the shoe on the base of the big toe.
  • Physiotherapy: Walking barefoot, as well as exercises for the legs and feet can strengthen the muscles and ligaments of the foot.When performing special exercises, the patient trains the muscles and learns to keep the fingers straight. This contributes to a slower progression of the disease.
  • Operation: if conservative treatment is ineffective and there are no contraindications to surgical treatment, the patient can be offered surgical correction. There are various surgical techniques for straightening the toe.

Comfortable flat-soled shoes with a wide toe are one of the methods of preventing hallux valgus.

High-heeled footwear, on the other hand, promotes deformation. The fact is that the heads of the metatarsal bones in this case must withstand a much greater load.

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Medi compression hosiery and orthopedic insoles

Compression hosiery for people with hallux valgus

Source:

1 Comfort is top priority: how shoes influence the onset of hallux valgus.Dr Armin Schupp from the Centrum für Orthopädie und Chirurgie (Center for Orthopedics and Surgery) in Memmingen, Germany

Services Surgery Ingrown nail in Krasnoturinsk

An ingrown nail is an ingrowth of the lateral part of the nail plate into the nail fold. Most often, the nail on the thumb is prone to ingrowth. The disease is accompanied by severe pain and redness of the skin, and the site of ingrowth becomes inflamed. The pain increases significantly when walking.

Reasons:

  • Incorrect pedicure (cutting corners of toenails)
  • Injuries to feet, toes
  • Tight, tight shoes
  • Fungus on the legs
  • Stiff seam socks or tights at toe
  • Hereditary form of nails and nail rolls

Stages of ingrowth

  1. Redness, swelling and pain.
  2. The infection joins. An ingrown nail behaves like a foreign body, swelling and suppuration appears.
  3. The nail phalanx is deformed, the disease becomes irreversible.

Treatment:

At the first stage, conservative treatment of an ingrown nail is possible, but it is very long and in this case there is a high probability of relapse. The surgeons of the “OLMED” MC recommend an operative method of treating an ingrown toenail.

During surgery for an ingrown nail, the nail plate is resected with the removal of the ingrown nail area, as well as the reversal of the nail fold.This operation is an alternative to removing the entire nail plate, as well as the prevention of recurrence of ingrowth. In addition to the operation, the surgeon of the MC “OLMED” conducts an explanatory conversation with the patient on how to avoid ingrowth, how to properly care for the legs and nails.

The operation is performed under local anesthesia on an outpatient basis and takes a maximum of 30 minutes. After the operation, the patient is observed for half an hour and goes home. Further observation and dressings are also carried out on an outpatient basis and do not require hospitalization.If the suture technique is used during the operation, then the sutures are removed for 5-7 days.

In the MC “OLMED” the cosmetic aspect of the operation is also provided. Scars on the finger are subtle and do not cause discomfort to the patient.

Prevention of nail ingrowth:

  • Trim toenails in a straight line, not oblique
  • Wearing comfortable shoes that match size

Occasional wear of open-toed shoes (sandals, sandals, flip-flops, etc.)and walking barefoot.

90,000 causes and symptoms, diagnosis, treatment and prevention

Symptoms of felon

The first sign of the disease is throbbing pain, swelling and redness of the skin around the nail (in the lower, lateral or upper part). Soon, a pus-filled blister appears under the skin, and the pain syndrome becomes more and more intense. The area of ​​inflammation of the subcutaneous panaritium gradually expands, and the inflammatory process itself is directed inward, spreading to the tendons and joints.

Varieties of the disease

  • If a splinter with dirt particles gets under the nail, then felon develops directly under the nail.
  • Periungual felon often occurs after manicure treatment of nails, when the master injures the skin fold adjacent to the nail.
  • Bone felon is often the result of an open fracture or a complication of subcutaneous suppuration.
  • Articular panaritium is localized between the phalanges.This process occurs with injuries of a limb, when putrefactive bacteria enter the joint.
  • Tendon panaritium (tendovaginitis) is one of the most severe forms of a purulent process. With this disease, the fingers become very swollen and lose their mobility. It is impossible to straighten them because of the strongest pain.

Treatment of panaritium

It is easiest to cure subcutaneous and periungual felon at the initial stage, when a purulent bladder has not yet formed and there is no pronounced swelling.Local antiseptics are used as medicines (baths with furacilin or miramistin). At night, apply compresses of chamomile, plantain, oak bark. If the patient has consulted a doctor when the purulent capsule has already formed, then a surgical opening is prescribed, followed by washing and drug treatment of soft tissues.

In case of subungual panaritium without detachment of the nail plate, the root of the nail or the distal part of the nail is resected (according to indications).If the nail exfoliates, a complete resection is indicated, after which the wound is closed with an antiseptic ointment and a bandage is applied.

Panaritium on the toes often develops as a result of ingrown toenails. At the initial stage of the process, the doctor prescribes compresses with antiseptics, dressings with antibacterial ointment, and alcohol lotions. When the form is neglected, nail resection, tissue dissection followed by antiseptic treatment is used.

If you find signs of panaritium, contact the specialists of our clinic, who will provide you with effective assistance under reliable local anesthesia.The earlier you make an appointment with the surgeon, the faster and more successful the treatment will be.

possible causes, possible diseases, therapy methods, reviews

A growth on the big toe worries so many people, so it is important to know for what reasons it appears and what diseases it may be associated with in order to carry out timely complex treatment.

A similar problem occurs in both sexes and brings many inconveniences. A person forgets about the desired shoes, since he has to wear the one that will be comfortable.In addition, pain during movement and deformity of the foot are often observed.

Basic classification

A growth on the big toe can be of several types, namely:

  • solid neoplasms;
  • soft;
  • cones.

Hard growths are often formed in the course of various diseases, in particular, such as gout. Lumps appear in the area of ​​deformity of the fingers. Soft growths can be warts or calluses that contain fluid.

Causes of occurrence

The main cause of the growth on the big toe, the photo of which allows you to visually identify the problem, is the deformation of the metatarsal bones. It is formed as a result of a disturbance in the normal balance between the toes and the heel. As a result, a bone neoplasm appears, which contributes to an increase in the load.

A build-up on the big toe is formed under the influence of various factors, which include such as:

  • narrow and uncomfortable shoes;
  • flat feet;
  • pregnancy;
  • high-heeled shoes;
  • flat feet; 90,062
  • obesity;
  • hereditary factors;
  • deterioration of metabolic processes.

Bone build-up is referred to as hallux valgus. If it is not eliminated in a timely manner, then there is a high probability of deformation of the entire foot, which leads to a lack of coordination and creates certain difficulties in movement.

Potential diseases

A growth near the big toe may be a wart or papilloma. Their formation occurs due to infection with a virus and a weakening of the immune system. Such growths look completely unaesthetic and are often found in childhood.Comprehensive treatment allows you to cope with the problem, however, until the moment of complete recovery, it is not recommended to wear open shoes.

One of the common causes of the formation of an inflamed growth on the big toe is gout. The disease occurs when a metabolic disorder occurs, in which uric acid is not completely excreted from the blood. Then it crystallizes on the cartilage tissue of the joints, provoking the formation of a tumor of the joint capsule during an acute attack of gout.

If treatment is not carried out in a timely manner, then in a few years the accumulation of uric acid will lead to the fact that a person will not be able to move normally.

A round lump occurs in bursitis, arthrosis, psoriatic and gouty arthritis. Initially, slight swelling develops as a result of soft tissue inflammation. Such a lump is warm and mobile to the touch. Among the causes of the growth, doctors call infectious diseases.

Growths on the nail plate

Many people ignore the first signs of problems with the nail plate. They believe that everything will go away on its own and no special treatment is required.However, if an outgrowth appears on the big toe nail, then this problem should not be ignored, as there can be very serious consequences. If such a pathology is accompanied by pain and redness, then there is a high probability of an inflammatory process.

Among the main reasons for the appearance of a growth on the big toe nail, it is necessary to highlight the following:

  • fungal diseases;
  • ingrown nail; 90 062 90 061 psoriasis;
  • papilloma virus.

In the initial stage of fungal disease, the skin around the nail plate is affected. To the touch, it presents a very coarse skin, which is often cut off.

An ingrown nail is accompanied by severe painful sensations, severe itching and purulent discharge. In the initial stages of the formation of a build-up, it does not exceed a small pea in size.

Psoriasis of the nails is characterized by a rather strong deformation of the nail. Together with the yellowing and destruction of the nail plate, the formation of small flesh-colored growths is observed.Human papillomavirus can also cause small growths to form under or near the nail. They very rarely exceed the diameter of a match head in size. The growths themselves are white and somewhat rough to the touch. Pain occurs only if the affected area is injured.

Penetration of a foreign body under the skin also provokes the formation of a build-up on the side of the big toe. Another reason is nail trauma. After its detachment or deformation, the formation of small growths can be observed.

Signs and symptoms

A pathological growth on the big toe, the photo of which allows you to recognize the pathology at the initial stage, grows slowly and can have a hard or soft structure. To distinguish a bump on the joints from a deformity of the foot, you need to move your big toe slightly to the side. If he calmly moves away and no painful sensations are observed, then this indicates that there is no deformation of the foot.

If discomfort is observed when pushing back the thumb or efforts are needed, then this may indicate the formation of a bone build-up.Painful sensations arise after the deformation has become visually noticeable. If pathological symptoms occur, you must definitely visit a doctor for diagnostic measures.

Carrying out diagnostics

To carry out diagnostics, a doctor’s examination is initially required to determine the degree of pathology. After that, an X-ray is assigned to the person, which shows changes in bone tissue.

When diagnosing, plantography is used, with which you can determine the stage of possible flat feet and set the level of load on the foot.The final stage of the study is podometry, which determines the degree of pressure on the feet. Based on the diagnostics performed, the doctor selects a therapy method.

Feature of treatment

Degenerative changes, in which a growth is formed on the joint of the big toe, is almost impossible to stop. To stop the growth of the lump, you need to treat the underlying disease, change your usual diet and lifestyle. In addition, the use of drugs, ointments, folk remedies, as well as wearing comfortable shoes is required.All of these methods work together to help reduce inflammation and pain. In some cases, it may be necessary to surgically remove the growth on the big toe. Among the conservative methods, it is necessary to highlight such as:

  • the use of tablets, ointments, injections;
  • anti-inflammatory drugs;
  • application of orthopedic insoles;
  • a set of special exercises;
  • physiotherapy;
  • balneological treatment;
  • massage.

Treatment of an outgrowth on the bone of the big toe, which occurs against the background of bursitis, arthrosis, gout, is a long and complex process. It is necessary to use medications, therapeutic exercises, physiotherapy, and it is also important to follow a special diet.

Medicines should be taken to lower uric acid and normalize kidney function. Special preparations containing colchicine and steroids will help to reduce painful manifestations and inflammation in the growth area.Applications with paraffin, “Dimexid” are also used.

Drug therapy

Treatment of a growth on the big toes is carried out with the use of drugs. For this, pain relievers and anti-inflammatory drugs are used. Lump therapy is based on eliminating the underlying cause that led to the onset of the pathology.

If the growth is an independent disease, then the doctor prescribes medications that help eliminate painful sensations in the joints and the bone of the finger.Local remedies are often used. These can be creams, gels or ointments, in particular, such as Voltaren and Diclac gel.

If a patient has inflammation of the joints around the thumb, then medications are prescribed to help eliminate the inflammation. For this, Ibuprofen and Nimesulide are used.

The disadvantage of anti-inflammatory drugs is a negative effect on the stomach. Side effects are much stronger when taking pills inside.To avoid damage to the stomach lining, the frequency of administration and dosage must be strictly observed.

Surgical intervention

If, using conservative techniques, it was not possible to get rid of the growths on the big toe cone, then the treatment is carried out by surgical intervention. Previously, operations were resorted to only in exceptional cases, since it was believed that they were quite dangerous.

Now there are many different techniques that are completely safe for humans.To get rid of a build-up on the big toe, the following techniques are used:

  • minimally invasive correction;
  • chevron osteotomy;
  • osteotomy scarf.

Minimally invasive correction means that the surgeon makes 2 small incisions near the thumb bone and aligns its location. When performing a scarf osteotomy, manual correction of the position of the finger is performed, after which the phalanx is fixed with small screws made of titanium.

Chevron osteotomy means that the growth is excised and then fixed with a screw and titanium wire. They need to be removed after a few months.

Often the postoperative period takes 1 month. The patient at this time is advised to wear special shoes during the day and a bandage while sleeping. When 2 months have passed, wearing orthopedic structures is stopped, however, comfortable shoes are required to avoid relapses.

In addition, the patient is additionally prescribed anti-inflammatory drugs and physical therapy sessions, which will allow much faster restoration of fingers, which had growths.

Folk methods

Skin growth on the big toe cannot be cured with folk remedies, but you can only eliminate unpleasant symptoms. It is necessary to resort to such funds only in combination with conservative treatment and after consulting a doctor.

Compresses made from chicken bile are recommended for treatment. It is prepared according to the instructions for use. It is recommended to resort to such a procedure daily until the bump on the leg passes.It is preliminarily recommended to steam your legs, apply an iodine mesh and then apply a medical compress.

You can also apply a compress with castor oil, which can be purchased at the pharmacy. Using a similar remedy for 2 months, until the unpleasant symptoms disappear.

Orthopedic aids

In the fight against growths on the thumb, special correctors and fixators have proven their worth. Their main advantage is that a person may well lead his usual way of life and maintain full-fledged physical activity, as well as fight the existing pathology.

Often, the patient is prescribed a valgus splint. It promotes a gradual return of the joint to its natural position, and also significantly reduces the size of the deformity. Wearing a splint allows you to relieve the foot, reduce pain, and stop the subsequent progression of the disease.

Orthopedic shoes will help to eliminate pain. It will not provoke friction, it will allow you to correctly distribute the load on the foot when walking, which will reduce painful manifestations.For orthopedic purposes, special insoles are also used that can be inserted into ordinary or orthopedic shoes. To achieve a positive result, it is best to select them according to individual parameters.

Other methods of treatment

To get rid of the growth under the big toe, it is recommended to carry out massage measures not only to treat this type of deformity, but also as a preventive measure. The main purpose of the massage is to strengthen the muscles. In addition, such a procedure helps to normalize the blood supply to tissues and reduce the intensity of inflammation, as well as minimize pain.

At the initial stages of growth of the build-up, special gymnastics is of great importance. Exercises for additional strengthening of the foot in conjunction with wearing orthopedic shoes will help completely eliminate the problem.

Diet

For any medication to be effective, you need to change your usual diet. The main task of dietary nutrition is to reduce uric acid in the blood, which is responsible for the deposition of salts. It is imperative to reduce your protein intake.You only need to consume fish, meat and legumes 1-2 times a week. You also need to cut back on your fat intake.

Nutritionists recommend increasing the amount of water consumed. You need to drink at least 2-3 liters of water per day, including at night, so that urine does not linger in the body for a long time. A special therapeutic diet helps to reduce the level of harmful processes in the body, reduce weight and normalize blood pressure. It is important to lose weight and stop drinking alcohol.

Prophylaxis

To prevent the formation of hard or soft growths on the big toe, preventive measures must be taken.As a preventive measure, it is recommended to refuse wearing excessively uncomfortable and tight shoes, as well as high-heeled shoes. In addition, preventive measures include:

  • regular warm-up and exercise for the feet;
  • massage;
  • moderate physical activity;
  • Compliance with the basic rules of good nutrition.

Lumps and growths on the legs are far from a harmless manifestation that requires proper, timely treatment.In its absence, the deformation of the foot can lead to more dangerous consequences, up to the complete loss of the ability to move freely. That is why, it is important to timely recognize the course of the pathology and conduct therapy.

Responsible attitude to your own health will help you notice the problem in time and quickly get rid of it.

Feedback on the treatment

Feedback from patients on the treatment is quite positive. Some say that you can quickly and effectively cope with the existing problem by wearing special orthopedic correctors and orthopedic shoes.

Surgical intervention also has good reviews. This procedure helps to effectively get rid of the existing problem. Recovery is quite painful, but the result is very good.

In order to quickly and effectively get rid of a build-up and a bump, it is important to pay attention to the presence of a problem in a timely manner. If you start treatment at the initial stage, then you can get rid of the problem with conservative methods without resorting to surgical intervention. 90,005 90,000 hurts under the toenail – 25 recommendations on Babyblog.ru

What a chubby he is, I’m a bastard! Some clothes don’t fit on the chest, ahaha)))

Bodysuit we wear in size 80, some sweaters too, the rest is 74. An acquaintance with a son two days younger said that it was not very big, only wide. She took away size 68 from me, by the way, which won’t fit on Rodya. It seems like it doesn’t look too big, and it doesn’t weigh a ton, it’s probably about proportions. And I wanted to buy him a suit in advance for the winter size 74. What a fine fellow I am that I did not buy it.It is not winter yet, and he is no longer drowning in his 86. It is clear that there is a decent margin, but if you wish, you can stretch your arms and legs so that it will be very good. I don’t pull it out, and my son is indignant.

He just hates sleeping bags and overalls because he can’t kick them off. The blanket throws off in an instant, right in a dream, kicks on the crib so that the crib is shaking. I try to shift it at night, but in the morning I cannot physically. Often wakes up every hour throughout the night. I’m already exhausted, but I’m holding on.Trying. Recently I fell off the couch, because in the morning I thought that I would not sleep anymore, and lay on my back, everything was numb, hold him. And passed out! And he crawled more than a meter diagonally and thumped. The height is only 30 cm, the floor is wooden, presumably overturned. I didn’t even hit, didn’t cry from pain, only got scared. I thought at that moment that I was a bastard.

Stands with support if you put your fingers in his handles. Holds at waist level and stands. Sits the same way. Where are you in a hurry? On all fours dives headfirst))

I don’t directly massage, sometimes I just iron.We do gymnastics and exercise on fitball. We are also working in the bathroom. He drowns in the circle, swim is also cramped, so I put him on his back and draw water to cover his ears, and he flounders first on his back, then I help him to roll over so that he does not gorge himself, and he rages on his stomach. It was in the water for the first time that I began to get down on all fours. Loves water, very happy there.

Hates jumpsuit and carrycot. Screams until he falls asleep, and even though you burst. I physically cannot drag him and carry the stroller, so I listen to Op for a while, hiss and roll the stroller back and forth.When Alya is also naughty at this moment, I want the children to walk themselves, and I go home, under a blanket with a cup of coffee))))) Fortunately, she falls asleep pretty quickly. Stubbornly I do not want to transplant for a walk, because it is warmer in the cradle. But he would have sat quietly there, lay, or rather, I went through all this with Alya. But then the spring was warm, and now it is getting colder every day, winter is on the nose.

Emotional. Laughs often and talks a lot. Loves attention. I was lying on the kitchen floor, playing calmly, and when I left, I burst into tears, began to call.He wants to watch cartoons, he needs a computer and a phone. This was not the case with Alya. And he is very inquisitive, he is interested in everything.

With dreams it is not clear at all. If he sleeps three times, do not go to bed at night. If two, by the evening moody. Or falls asleep late for a second sleep and leaves into the night, but wakes up and hangs out later in the night. Two dreams are not enough, three are many. We are walking now, so one dream is in the past. It is very difficult, if not impossible, to lay it. At least swing, at least dance. It is necessary that he himself wants to. For two weeks he fell asleep once, usually asks for help, cries.

Understands words. I ask you to bend your legs when I wash, listens. And then I got into the habit of jumping out of the shell. I do not allow me to roll over when I change my diaper, I also understand and obey. He scratched my hand, twice asked me not to do that, stopped. I explain that you cannot roll over in the bathroom yourself, because sips. He took a bite a couple of times, now he shows that he wants to roll over and I help. My clever girl!

Constantly jerking, constantly moving. Before getting on all fours, he stopped crawling.Apparently, he was preparing. Now he is moving, but not fast, and only towards the goal. Alina crawls to the car and lies spinning the wheels, the auto mechanic))))))))))))))) I want to crawl on all fours.

Nail trim problem. I suffer from birth, pulls out my hands even in a dream. Lately I’ve been putting him on my knee, holding him so that he doesn’t quite sit, and I’m quickly cutting my hair. And he looks and tries to pick up the scissors.

A parcel arrived from the USA with clothes in sizes 12m and 18m (and pants 9m), 12m can already be worn a lot, which is what we are doing.9m pants are good too. No longer needed, legs are not very long. Everything is so beautiful, I would wear it myself)))

Has become more demanding. One plays less. You need a company, and sometimes there is simply no mood. On days like these, I wrap myself in a sling so that it is calmer, and I rested. My back hurts, but it’s morally easier. He will sit there and fall asleep.

My sweet boy!

I love it!

Photo later, in one post with Alya. How will it be time to throw off.

90,000 What is subungual melanoma, its photo, symptoms, treatment and prognosis

24.05.2018

Many people who find a speck under their fingernails start looking on the Internet, what could it be? And it turns out that it can be a fatal disease – subungual melanoma.

In this article we will analyze:

  • The concept of subungual melanoma;
  • 90,061 chances of this type of tumor occurring;

    90,061 photos of symptoms with histological confirmation;

  • Ways to distinguish subungual melanoma from hematoma;
  • procedures to clarify the diagnosis;
  • prognosis and treatment.

Subungual melanoma – what is it?

The share of melanoma among skin formations is only 4%. But it is from this malignant neoplasm that 80% of patients with skin tumors die [1]. In Russia, at the moment, about 8,717 people fall ill with skin melanoma per year (data for 2012) [2]. Subungual melanoma is located in the area of ​​the nail bed and usually looks like a strip on the nail.

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What are the chances of this type of tumor in a resident of Russia?

Of the total number of melanomas, the share of this tumor is only 2% [3], ie, in absolute values ​​in 170 people per year. Against the background of the country’s total population of 146 million, this, in my opinion, is very small. At the same time, a low incidence rate does not negate the possibility of getting sick.

For representatives of other skin phototypes than the 2nd, the chances may vary greatly. Representatives of the Mongoloid and Negroid races have a higher (up to 40%) chance of developing nail bed melanoma [4, 5].

Where does subungual melanoma occur more often?

The tumor often affects the big toes [3].

What does subungual melanoma look like? Photos and signs.

All pictures below are histologically confirmed and not taken from the Internet. The source is indicated in square brackets. There are 2 most common signs:

Feature I

Subungual melanoma most often appears as a brown or black streak. The strip starts at the nail bead and ends at the edge of the nail.This condition is called longitudinal melanonychia. Some drugs can cause these streaks – retinoids and Docetaxel (Taxotere) [10]. This symptom can also be in conditions not associated with melanoma, for example, with a fungal infection of the nail, a pigmented nevus of the nail bed.

Subungual pigmented nevus in a 13-year-old boy [9]

Subungual melanoma grade I, 0.2 mm Breslow [10]

Feature II

The most common symptom of this type of melanoma is Hutchinson’s symptom – the transition of pigmentation to the nail fold or fingertip.7 out of 8 images below show this sign. At the same time, it cannot be unequivocally stated that this symptom occurs only with melanoma. It can also be observed with a transparent cuticle [10].

8 cases of subungual melanoma in situ (initial stage) [6]

Subungual melanoma of the thumb with the 4th level of invasion according to Clarke, thickness according to Breslow is not specified [8]

Subungual melanoma, Breslow thickness 1.5 mm [7]

How to distinguish subungual melanoma from everything else?

Here’s a fairly simple algorithm.

Algorithm for differential diagnosis of benign melanonychia and the same condition in melanoma [8]

ABCDEF rule in the diagnosis of melanoma of the nail bed

A (age) age – the peak incidence of subungual melanoma occurs at the age of 50 to 70 years, and also denotes races with an increased risk: Asians, Africans – they account for 1/3 of all cases of melanoma.

B (brown to black) – color brown and black, with a strip width of more than 3 mm and vague borders.

C (change) – change in the color of the nail plate or no changes after treatment.
D (digit) – finger as the most common site of injury.

E (extension) – spread of pigmentation to the nail roller or fingertip (Hutchinson’s symptom).

F (Family) – in relatives or in a patient, past melanoma or dysplastic nevus syndrome. [11]

How to distinguish hematoma from subungual melanoma on dermatoscopy

Hematoma: [10]

  1. Moves under the nail along with its growth.You can track this by taking a photo of the formation against the background of a ruler located longitudinally. It is important to note that a hematoma does not always appear due to trauma.
  2. Color from red-blue to black-blue.
  3. Does not transfer to cuticle, nail fold and fingertip.
  4. Does not involve the entire nail in the longitudinal direction.
  5. May vary within a few weeks.
  6. The intensity of the color decreases from the center to the periphery.
  7. It may be preceded by an injury.
  8. Small blood points oriented towards the edge of the nail, with dermatoscopy

Subungual melanoma: [12]

  1. Inhomogeneous color, irregular stripes with melanonychia.
  2. Triangular stripes.
  3. Distributed on the nail plate, free edge of the nail or the tip of the finger.
  4. Destruction or degeneration of the nail.

How is the diagnosis made?

If you suspect melanoma of the nail bed, there are 3 options for the development of events:

  1. Observation with photographs and repeated examinations.
  2. Biopsy with partial removal of the nail plate.
  3. Biopsy with complete removal of the nail plate.

The resulting material is sent for histological examination.

Treatment of subungual melanoma

As a rule, we are talking about the amputation of the finger.Recently, many researchers are inclined to amputate the phalanx instead of the entire toe. There are also works in which it is shown that the amount of indentation does not affect the forecast.

Forecast

As with melanomas of other localizations, the prognosis directly depends on the results of histological examination. At the same time, it should be noted that the prognosis for subungual melanoma is somewhat worse than for the location in the rest of the body. The smaller the Breslow thickness, the better the forecast.

CV

Subungual melanoma is a tumor that is difficult enough for early diagnosis. The most common signs are the presence of a streak on the nail and the transition of pigmentation to the nail roll or fingertip. If you find yourself with one of these symptoms, you need to see an oncologist.

P.S .: If you find yourself at an appointment with a dermatologist or oncologist, show him your nails. If you are using nail polish, it is best to remove it before taking.

References

  1. Miller AJ, Mihm MC.Melanoma. N Engl J Med. 2006; 355: 51-65.
  2. Data from Globocan 2012 study, International Agency for Research on Cancer (IARC): http://gco.iarc.fr/today/online-analysis-multi-bars?mode=cancer&mode_population=hdi&population=643&sex=0&cancer=29&type=0&statistic=0&prevalence = 0 & color_palette = default
  3. Kuchelmeister C, Schaumburg-Lever G, Garbe C. Acral cutaneous melanoma in caucasians: clinical features, histopathology and prognosis in 112 patients // J.Dermatol. – 2000
  4. Takematsu H, Obata M, Tomita Y. Subungual melanoma. A clinicopathologic study of 16 Japanese cases // Cancer. – 1985
  5. Wu XC, Eide MJ, King J. Racial and ethnic variations in incidence and survival of cutaneous melanoma in the United States, 1999–2006 // J. Am. Acad. Dermatol. – 2011.
  6. Jae Ho Lee, Ji-Hye Park, Jong Hee Lee, Dong-Youn Lee. Early Detection of Subungual Melanoma In Situ: Proposal of ABCD Strategy in Clinical Practice Based on Case Series Ann Dermatol.2018 Feb; 30 (1): 36-40.
  7. Stephan Braun, MD and Peter Gerber, MD. Subungual malignant melanoma. CMAJ. 2015 Sep 8; 187 (12): 909.
  8. Pierre Halteh, Richard Scher, MD, FACP, Amanda Artis, MS, MPH, and Shari R. Lipner, MD, PhD. A Survey Based Study of Management of Longitudinal Melanonychia Amongst Attending and Resident Dermatologists. J Am Acad Dermatol. 2017 May; 76 (5): 994-996.
  9. Kamran Khan and Arun A Mavanur. Longitudinal melanonychia. BMJ Case Rep.2015; 2015: bcr2015213459.
  10. Holger A. Haenssle, Andreas Blum, Rainer Hofmann-Wellenhof, Juergen Kreusch, Wilhelm Stolz, Giuseppe Argenziano, Iris Zalaudek, and Franziska Brehmer. When all you have is a dermatoscope— start looking at the nails. Dermatol Pract Concept. 2014 Oct; 4 (4): 11–20.