Dermoscopy of Subungual Exostosis: A Retrospective Study of 10 Patients.

INTRODUCTION: Subungual exostosis (SE), the most common nail tumor of young adults, is a benign bony proliferation of the distal phalanx occurring beneath the nail. Misdiagnosis or late diagnosis frequently occurs and no dermoscopy features of this tumor were previously outlined. MATERIAL AND METHODS: To describe the dermoscopic appearance of SE, 10 patients with radiologically and histologically confirmed SE were retrospectively retrieved from our tertiary referral centers. Data regarding age, gender, time to diagnosis, clinical presentation, dermoscopic features, involved nail and history of trauma were recorded for each patient. RESULTS: In our patients, clinical findings were similar to previous reports. Among the dermoscopic features, vascular ectasia was the most common finding (70%), followed by hyperkeratosis (60%), onycholysis (40%), and ulceration (30%). CONCLUSION: Dermoscopy could be a useful technique aimed at creating diagnostic suspicion of this benign nail condition, although X-ray examination and histopathology are mandatory for the diagnosis.

Postoperative electron beam irradiation to prevent recurrence of refractory subungual exostosis: a case report.

Background: Subungual exostosis is a type of heterotopic ossification, which often has unclear margins. Therefore, marginal resection may cause recurrence and wide resection is sometimes required to achieve a complete cure. However, wide resection may cause postoperative nail deformity and revision of this deformity is generally difficult. The primary treatment of subungual exostosis is surgical treatment, and there have been no comprehensive reports on the efficacy of adjunctive treatments. Although postoperative electron beam irradiation has been successfully used after heterotopic ossification excision to prevent recurrence, there are no reports on the use of this procedure following subungual exostosis resection. Case Description: Herein, we report a case of refractory subungual exostosis that developed as a result of chronic irritation and inflammation caused by an ingrown nail and recurred after initial resection. We performed marginal resection of the lesion to preserve the nail matrix and nail bed as possible, a two-stage skin grafting procedure, and electron-beam irradiation to prevent recurrence. Conclusions: Excellent results were achieved both in terms of complete cure and cosmetic appearance, suggesting that electron-beam irradiation following refractory subungual exostosis excision may help prevent its recurrence. We expect a further study including many cases of subungual exostosis treated with postoperative electron-beam irradiation to be conducted.

Infrequent Pediatric Subungual Injury Diagnosed by Intraoperative Anatomopathological Material: A Case Report.

Subungual lesions are very common in clinical practice. We present the clinical case of a 10-year-old female patient who presented with progressive nail deformity. The onset of the condition was approximately five years prior to presentation with an injury in the left hallux, according to the mother. She denied pain or change in the color of the area from the onset of the injury to the day of consultation. There was no previous trauma. Examination revealed subungual bone injury to the distal extremity (distal phalanx of the left hallux), and imaging tests (X-ray and soft tissue ultrasound) found bone injury. Subungual exostosis was considered as a possible diagnosis, thus prompting the indication for exeresis of the tumoral process. After surgical removal, the resected specimen was sent for pathological assessment, which found that an intraosseous hemangiolymphangioma was the origin of the tumor. A subungual exostosis is a slow-growth benign osseous tumor mainly located in the distal phalanx of the hallux that especially affects young adults, being less frequent in children. This condition results from a process of bone neoformation involving different stages, the clinical symptoms of which depend on its size and associated processes. Hemangiolymphangiomas are angiomatous lesions of the blood and lymphatic vessels that have a controversial etiology and present slow, painless, and progressive growth; these lesions are mostly benign. It is worth emphasizing that subungual injuries are not always caused by an underlying bone; therefore, potential differential diagnoses, both benign and malignant, should be considered, based on the location of the injury.

The Influence of Clinical Factors on Treatment Outcome and a Recurrence of Surgically Removed Protruded Subungual Osteochondroma and Subungual Exostosis.

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.

Clinical diagnosis and treatment of subungual exostosis in children.

Objective: To analyze and summarize the clinical characteristics and treatment effects for subungual exostosis in children. Methods: Clinical data for children with subungual exostosis treated in our department from January 2008 to September 2022 were evaluated. Results: Forty children with subungual exostosis were evaluated, comprising 31 boys (77.5%) and 9 girls (22.5%) with a median age of 9 years (4-17 years). The median disease course was 6 months (1-48 months). Seven patients (17.5%) had definite trauma history and 5 (12.5%) had infection. The toe or finger nail appearance was abnormal in 36 patients and normal in 4 patients. Twenty-seven patients (67.5%) had pain when wearing shoes and walking, and 25 (62.5%) had toenail tenderness. The lesions were located in the distal phalanxes of the toes in 37 patients (92.5%), with 14 patients affected on the left side and 23 on the right side. Twenty-two patients had lesions in the great toe, 6 in the second toe, 6 in the third toe, and 3 in the fourth toe. The lesions in the other 3 patients (7.5%) were located in the distal phalanxes of the fingers, with 2 patients affected in the second finger and 1 in the third finger. Regarding the relationship between lesion location and nail bed, 4 patients were type I, 21 were type II, and 15 were type III. All 40 patients received surgical treatment, with nail removal in 15. The median maximum lesion diameter was 1.0 cm (0.8-2 cm), median operation time was 25 min (20-45 min), median blood loss was 1 ml (1-2 ml), and median postoperative hospital stay was 2 days (1-4 days). All cases were histopathologically confirmed as subungual exostosis. The median follow-up time was 24 months (3-60 months), with normal appearance of the toe or finger nail. There were no complications in 38 patients (95.0%). Two patients (5.0%) relapsed at 3 months postoperatively and underwent a secondary operation, with no subsequent recurrence during 12 months of follow-up. Conclusion: Subungual exostosis in children is a rare benign disease that often occurs in the toes. Selection of the appropriate incision and nail bed treatment based on the relationship between lesion location and nail bed is helpful for improving the treatment effect.

Subungual Exostosis Presenting as a Pyogenic Granuloma-like Lesion with Reactive Myofibroblastic Proliferation in Two Young Women.

Subungual exostosis (SE) is a well-recognised benign proliferation of the distal phalanx most often seen in young adults and affecting the big toe. Possible triggers include previous trauma and chronic irritation or infection. We describe two atypical cases of SE in two young women presenting with pyogenic granuloma-like lesions clinically. Diagnostic biopsies were performed to confirm the diagnosis and excluded amelanotic melanoma. However, histology unexpectedly revealed reactive myofibroblastic proliferations mimicking nodular fasciitis overlying the SE. Given the atypical clinical presentation, the diagnosis was initially missed or not considered in both patients. They highlight two important points; the first is that SEs may present with pyogenic granuloma-like lesions clinically and that histological analysis is then required to exclude malignancy, particularly amelanotic melanoma. Secondly, that the histology will show a reactive myofibroblastic proliferation and if the sample is relatively superficial and pathologists are not aware of this potential reaction pattern, the underlying diagnosis of SE may be missed.

A Subungual Exostosis Mimicking a Periungual Granuloma in a 9-Year-Old Boy: An Unexpected Dermoscopic Pattern.

Subungual exostosis (SE) is an uncommon osteocartilaginous tumor. Classic dermoscopic features of SE include vascular ectasia, hyperkeratosis, onycholysis, and ulceration. In this case, a 9-year-old boy presented SE showing a dermoscopic mesh dilated blood vessel pattern surrounded by a scar-like peripheral ring, which represents a novel finding in the medical literature.

Subungual Exostosis: A Case Series of 48 Patients.

BACKGROUND: Subungual exostosis is an unusual benign nail tumor, mostly located on the big toe. It generally affects young people and manifests as uncomfort during footwear. METHOD: A monocentric retrospective study was conducted at the outpatient consultation for nail disorders at the Department of Dermatology of the University of Casablanca, Casablanca, Morocco, between April 2006 and October 2019. RESULTS: We diagnosed subungual exostosis in 48 patients, including 25 men and 23 women, with an average age of 20 years. The subungual exostosis was located on the hallux in 34 cases, the second toe in 10 cases, and the index finger in 2 cases. Nail trauma was found in 27 patients. The tumor was entirely excised in all the patients. CONCLUSION: Large series of subungual exostosis are reported by orthopedic surgeons. However, our outpatient consultation for nail disorders allowed the diagnosis and appropriate management of subungual exostosis.

Subungual exostosis recurrence in a 16-year-old athletic male.

Subungual exostosis is a painful, benign bony outgrowth projecting from the distal phalanx of the toes. The present case consists of a 16-year-old male that presented to the primary clinic with a single circumscribed painful lesion underneath the nail of the first phalanx of the left foot that recurred after surgical extraction.

Subungual exostosis of the finger in an 8-year-old girl.

INTRODUCTION: Subungual exostosis (SE) is a relatively uncommon benign bone tumor that occurs in the distal phalanges of the toes or fingers. CASE PRESENTATION: An 8-year-old girl presented for treatment of an acquired mass on the distal right index finger. The patient was preoperatively diagnosed with a benign bone tumor. Surgical resection of the distal right index finger mass was performed under general anesthesia, and histological examination of the resected tissue supported a diagnosis of SE of the right index finger. The surgical outcome was good, with no surgical site infection. Throughout 15 months of follow-up, the patient was asymptomatic with no recurrence. CONCLUSION: Surgical resection of a mass on the distal right index finger resulted in absence of recurrence during 15 months of follow-up. SE is a benign and uncommon lesion that is infrequently encountered by physicians. This infrequent occurrence may result in delays in diagnosis and treatment. Complete excision of the lesion and careful separation from underlying nail bed structures results in total resolution of the lesion, while providing the lowest risk of recurrence.

Surgical treatment of nail bed subungual exostosis.

INTRODUCTION: A subungual exostosis (SE) is a bony overgrowth that is permanently attached to the tip of the distal phalanx. Its pathology differs from osteocartilaginous exostoses in that it mainly involves the overgrowth of normal bone, which may present beneath the toenail or on the sides of the toe. This retrospective study aimed to report the results of surgical treatment when the diagnosis of SE was delayed; the condition was initially considered to be another pathology affecting a different nail or the terminal toe. METHODS: A total of 17 patients (12 female, five male) were included in the study. All surgical resections were performed by the same surgeon using the same surgical technique, with the patient under digital anaesthesia. The patients were evaluated pre- and postoperatively (on Weeks 1 and 6, the first year, and the last follow-up visit) using the American Orthopaedic Foot and Ankle Society questionnaire and the Visual Analogue Scale score. RESULTS: The patients underwent surgery for SE removal between December 2009 and October 2012. Their mean age was 21.3 ± 4.4 (range 14-29) years and the mean follow-up period was 27.1 ± 7.8 (range 18-45) months. Clinical or radiological recurrence was not observed in any of the patients during the follow-up period. Four patients had superficial infections, which were treated using appropriate antibiotic therapies. CONCLUSION: As SE is an uncommon benign lesion, its diagnosis may be delayed. Radiography may be useful in obtaining a differential diagnosis.

Dystrophy of the Great Toenail by Subungual Exostosis and Hyperostosis: Three Case Reports with Different Clinical Presentations.

Subungual exostoses and hyperostoses of the great toenail are a differential diagnosis of nail tumors. We present 3 cases of subungual exostosis/hyperostosis with secondary nail dystrophy: a 36- and a 37-year-old woman as well as an 8-year-old boy. Two of the 3 patients suffered from pain. The 2 female patients presented with the classic dorsolateral firm protrusion, while the child presented with bilateral nail dystrophy with lateral wall hypertrophy. In this later case, a bony ridge was identified, which is an unusual subungual, nonprotruding type of exostosis. The hypertrophic lateral walls were removed by the Vandenbos technique. In the 2 former cases, complete excision of the bony lesions was performed with a proximal block. Healing by second intention was uneventful.

Protruded and nonprotruded subungual exostosis: Differences in surgical approach.

BACKGROUND: In subungual exostosis surgery, repair of the damaged nail bed and surgical excision of the mass without damaging the nail bed is important. The ideal method of surgery is still unclear. This study is done to qualify the effects of different surgical methods on outcome measures in different types of subungual exostosis. MATERIALS AND METHODS: Fifteen patients, operated with a diagnosis of subungual exostosis between January 2008 and June 2012, were evaluated. Protruded masses were excised with a dorsal surgical approach after the removal of the nail bed and nonprotruded masses were excised through a"fish-mouth" type of incision. RESULTS: The mean age of the patients in protruded subungual exostosis group was 17.3 years (range 13-22 years) and this group consisting of seven female and two male patients. The patients were followed up for a mean of 14.1 ± 4.8 months. The mean age of the patients in the nonprotruded subungual exostosis group was 14.6 years (range 13-16 years) and consisting of six female patients. The patients were followed up for a mean of 11.6 ± 2.9 months. The results were positively affected by changing the surgical approach depending on whether or not the exostosis is protruded from the nail bed. All patients had healthy toe nails in the postoperative period without any signs of recurrence. CONCLUSIONS: In patients with a protruded subungual exostosis, the mass should be removed by a dorsal approach with the removal of the nail and injury to the nail bed should be repaired. In patients with a nonprotruded subungual exostosis, the mass should be excised through a "fish-mouth" type incision at the toe tip without an iatrogenic damage.

Preoperative Assessment Using Magnetic Resonance Imaging for Subungual Exostosis beneath the Proximal Region of the Nail Plate.

Subungual exostosis is a benign calcifying projection that occurs on the distal phalanx beneath or beside the nail. The problems in treatment are frequent postoperative recurrence and nail deformity or loss. Here, we describe the case of a male patient with a subungual exostosis beneath the proximal region of the nail plate of the right big toe. A precise preoperative evaluation of the anatomical structure using magnetic resonance imaging was useful for removing the subungual exostosis.