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BACKGROUND: Subungual exostosis (SE) and subungual osteochondroma (SO) are benign solitary lesions that grow from the distal phalanx. The mass itself is typically painless, but pressure on the nail plate can result in pain and deformity of the involved digit. Tumors can be correctly diagnosed based on clinical, histological and radiographic appearance alone. Surgical resection of SE/SO is typically curative, with a small risk of recurrence. METHODS: The study was retrospective and observational, involving 74 patients with subungual SE/SO. The surgical procedure consisted of the removal of the tumor from the dorsal approach under digital anesthesia. The procedure was assessed using a questionnaire and photo documentation after a minimum of 6 months after surgery. RESULTS: A total of 85% of respondents were satisfied with the procedure. Nearly 80% of patients rated the cosmetic effect as good or very good. Young age and pain intensity after surgery showed statistically significant associations with worse satisfaction. Age < 18 was associated with recurrence. CONCLUSIONS: Worse satisfaction is strongly associated with recurrence. Gender, duration of symptoms, pain before surgery and tumor size and destruction of the nail plate had no significant effect on recurrence. The technique using burr appeared to be a more effective treatment.

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Mixed tumors are well-circumscribed lesions exhibiting epithelial and/or myoepithelial cells and they usually occur in the skin and salivary glands. Soft tissue mixed tumors are extremely rare. Therefore, radiographic findings of soft tissue mixed tumors have very rarely been described in the radiologic literature. Here, we report a rare case of subungual mixed tumor in a 65-year-old female who presented with left 2nd finger pain, describe the radiographic findings, and discuss the differential diagnosis of the tumor.

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Glomus tumor is a benign neuromyoarterial tumor commonly found in the hand, particularly in the subungual region, that is removed only by surgery. Surgical excision leaves postoperative nail deformity and may cause a recurrence of subungual glomus tumors. A retrospective chart review was performed to assess the role of a synthetic nail shield in the prevention of postoperative nail deformity after transungual glomus tumor excision; the review was performed at a minimum of one year of follow-up of proven diagnosed 19 patients with digital glomus tumor between May 2011 and April 2016 in the orthopedic department in the university hospitals. All patients underwent surgical excision using transungual approach with a synthetic nail shield under digital nerve block anesthesia. Pain, cold intolerance, and complications were examined before and after surgery, and data were recorded. All patients had pain, tenderness, and cold intolerance, 12 patients (63.2%) had nail discoloration, and 3 patients (15.8%) had dystrophic changes. The tumors detached from surrounding tissues had an ovoid or round shape of 2-10 mm in size. Diagnosis was confirmed after pathological examination. In all patients, pain and cold sensitivity diminished. The mean follow-up period was 20.6 months, with no recurrences detected and improved nail appearance. No patient had postoperative nail deformity. Transungual approach followed by artificial coverage was an effective method for the treatment of glomus tumors without complications to the nail bed.

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E7 protein from cutaneous as well as mucosal HPV types can alter NF-κB activity. Conflicting literature data show a HPV-induced up- or down-regulation of the NF-κB pathway in different cell lines. In a previous study we detected the expression of E7 gene of HPV15 in a subungual tumor of a patient affected by incontinentia pigmenti (IP). IP is a rare X-linked genodermatosis in which the IKKγ gene is altered. From observations in transgenic IKKγ defective mice, it was suggested that IKK-deficient cells may undergo rapid hyper-proliferation and apoptosis/necrosis, leading to increased pro-inflammatory cytokine production in the neighboring IKK-positive cells. The objective of this study was to ascertain if beta HPV 15 can alter apoptosis and NF-κB pathway in normal and IKKγ-deficient keratinocytes. The human immortalized keratinocyte cell line (HaCaT), and human primary keratinocyte (HPK) cells were transduced with a retrovirus expressing E6-E7 proteins of HPV 15 and IKKγ was successful silenced mimicking the HPV15 infection and IP. HPV15 E6-E7 gene expression improved NF-κB activity in human keratinocytes even when IKKγ was silenced by siRNA. In IKKγ silenced keratinocyte cells, TNF-α-induced apoptosis was strongly reduced by the expression of HPV15 E6-E7 genes. Beta HPV15 exerted this anti-apoptotic activity by decreasing pro-apoptotic BAK and cleaved Caspase 3 proteins. In conclusion, we can speculate that presence of persistent infection by beta papillomavirus might influence the biological fate of IP by altering NF-κB activation and apoptosis in IKKγ mutated cells, favoring their survival and possibly the development of tumors in the late stage of disease. Taken together, our data reinforce the importance of host genetic background in the pathogenesis of HPV-associated skin lesions.

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BACKGROUND: Squamous cell carcinoma (SCC) of the nail bed is a poorly reported malignant subungual tumor. Because it presents with nonspecific symptoms and signs, it is frequently misdiagnosed by dermatologists or surgeons. A delay in diagnosis and/or wrong treatment might increase the possibility of disease progression. Thus, new perspectives are needed to assist dermatologists and surgeons with diagnosing and treating SCC. This rare case presented with a 2-year delay in the diagnosis of SCC teaches a valuable lesson. CASE SUMMARY: A 62-year-old female presented with a non-healing subungual growth in the nail bed of the right middle finger for 2 years. The lesion was first medicated with iodine by the patient herself without any relief. Twenty months later, a dermatologist diagnosed the lesion as paronychia and treated it with nail avulsions repeatedly with no obvious alleviation. A lesionectomy confirmed the lesion was SCC. An extended excision of the tumor with amputation of the distal interphalangeal joint was subsequently performed. A biopsy of sentinel lymph nodes was negative. Due to the result of preoperative positron emission tomography-computed tomography scanning, sweeping of axillary lymph nodes was considered dispensable and was skipped. At the 2-year follow-up, the patient showed a quick recovery and no sign of recurrence. CONCLUSION: Our successful diagnosis and treatment of the case highlights the need for additional attention to long-standing non-healing lesions of the nail bed and the necessity for discreet evaluation and customization of surgical interventions.

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OBJECTIVE: The aim of this study was to present an underutilized and underreported surgical technique in which the glomus tumors situated anywhere under the nail bed can be approached and removed with relative ease. MATERIALS AND METHODS: Over 3 years, four cases of subungual glomus tumors, which were surgically managed with this technique were presented. The technical ease, complications, and aesthetic appearance of the nail were studied and presented. The limitation of this study was the lesser volume of cases. RESULTS: This technique is easy to apply and gives aesthetically good results.

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Painful subungual tumor masses in the toes usually emerge as glomus tumors or subungual exostoses. We present a patient with an aneurysmal bone cyst located subungually in whom the diagnosis was delayed due to inadequate diagnostic procedures, which led to marked destruction of the distal phalanx of the great toe of the right foot. After biopsy, the distal phalanx could not be preserved due to critical soft tissue involvement and the size of the process. Thus, we describe this rare entity to encourage clinicians to establish the diagnosis by biopsy of a tissue swelling of unclear origin and duration that does not resolve after a short time. Imaging examinations are useful in demonstrating periosteal involvement and extension of the lesion and can be helpful in the diagnostic algorithm. An interdisciplinary approach is a top priority to ensure optimal treatment.

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UNLABELLED: Glomus tumor, originally known as an angioneuromyoma, is a benign neoplasm arising from specialized structures called glomus bodies, involved in thermoregulation. Although it has been reported at a number of sites in the body, this rare tumor is most commonly seen in the subungual areas of the digits of the hand. Only a handful of lesions have been reported in the toes. Because most foot conditions are treated by podiatrists and dermatologists, orthopaedic surgeons are generally unaccustomed to making early diagnoses. The purpose of this case report is to alert the attending surgeon regarding the possibility of glomus tumor as a cause of chronic toe pain. Also it has been observed that the behavior of this tumor varies with the site of occurrence-whether digital or extradigital. So we have extensively reviewed all similar reports in the literature to analyze the behavior of this tumor at this unusual location, apart from comparing it with the more common finger variety, to ensure it possibly is not a misclassification like the chemodectomas that were earlier thought to be glomus tumors. LEVELS OF EVIDENCE: Therapeutic Level IV: Case Study.

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Nail disorders are a common presenting complaint for both the primary care physician and the dermatologist. Nail diagnoses are broad in scope and include infectious, inflammatory, and neoplastic conditions. Onychomycosis is an especially common nail condition, and treatment should always be preceded by appropriate fungal studies for confirmation of diagnosis. Inflammatory conditions of the nail unit can mimic onychomycosis, and a dermatologist can assist with diagnosis and treatment recommendations. Likewise, subungual tumors often require biopsy, and should be evaluated by a dermatologist who is experienced in nail evaluation and treatment.

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"Subungual tumors are relatively rare; yet dermatologists are often called upon to examine, diagnose, and treat these patients. Many dermatologists do not feel comfortable performing surgical procedures of the nail unit. With knowledge of the nail unit anatomy and execution of few simple techniques, dermatologist can safely and effectively remove subungual tumors in the office setting. This article reviews the basic steps for removal of a subungual tumor. It discusses preoperative evaluation, highlights techniques to avoid complete nail plate avulsion, and touches on potential complications and postoperative care."

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