A Case of Subungual Wart Invading the Nail Root Successfully Cured with Surgery Combined with Photodynamic Therapy.

Sir,

A 25-year-old man visited our hospital for treatment of a subungual nodule in the right hallux. Two years ago, the patient had a small verrucous nodule on the medial side of the right hallux without itching or pain. The lesion proliferated and enlarged. It was diagnosed as a subungual wart, and cryotherapy was administered once every 2 weeks for a total of 11 sessions. The lesion did not heal and continued to grow, leading to bulging and cracking on the surface of the nail plate at the site of the skin lesion, and mild pain when walking.

Physical examination revealed the nail plate on the medial side of the right hallux was thickened and appeared turbid. Two full-nail full-layer cracks were seen extending to the nail margin. Verrucous bulging and scaling were seen at the crack sites [Figure 1]. Both direct microscopic examination and culture of nail fungi showed negative results. No significant bone abnormality was seen upon x-ray examination.

Figure 1

Two full-nail full-layer cracks were seen extending to the nail margin. Verrucous bulging and scaling were seen at the crack sites

Under the nerve block anesthesia, the medial nail plate was removed, then the skin lesion was resected a scalpel from the shallow to deep layer, with the depth controlled within the dermal papillary layer. On the nail bed at the nail root, a 1 × 0.6 cm white nodule was found, with a slightly rough surface and hard texture and was fixed by connecting the deep nail bed to the nail root [Figure 2]. Some tissues were resected for biopsy. Electrocauterization with a bipolar electrocoagulator was performed on the wound surface for the purpose of hemostasis and burning residual skin lesions. After 5 days, histopathology showed hyperkeratosis accompanied by parakeratosis; hyperplasia and hypertrophy of the stratum spinosum with papilloma-like hyperplasia; concentrated vacuolated cells and keratohyalin granules in the upper stratum spinosum [Figure 3a and b]. The diagnosis was verruca vulgaris.

Figure 2

A 1 × 0.6 cm white nodule was found on the nail bed at the nail root

Figure 3

Hyperplasia and hypertrophy of the stratum spinosum with papilloma-like hyperplasia; concentrated vacuolated cells and keratohyalin granules in the upper stratum spinosum. HE, (a) scale bar = 1 mm; (b) scale bar = 200 μm

The nodule was completely removed from the surface of the phalanges and the nail root [Figure 4]. The resected nodule was 1.2 × 0.8 × 0.6 cm [Figure 5]. The remainder was treated by electrocauterization with a bipolar electrocoagulator for haemostasis [Figure 6]. The wound was covered with a thin layer of medical cotton with a 3-mm scope. Then, 20% aminolevulinic acid solution was applied to the medical cotton and the wound was sealed with a surgical patch and wrapped in tinfoil. The cover was removed after 3 hours, and a semiconductor laser machine was applied for 20 min with a wavelength of 635 nm and an energy density of 100 J/cm2. After the irradiation, the wound surface was disinfected with iodophor, and wrapped with vaseline gauze and sterile dressing. Dressings were changed every 2 days. During the 7th and 14th days, removal of crust on the wound surface and photodynamic therapy were performed once.

Figure 4

The nodule was completely removed from the surface of the phalanges and the nail root

Figure 5

The size of the resected nodule was 1.2 × 0.8 × 0.6 cm

Figure 6

The wound was treated by electrocauterization for hemostasis

The wound healed 35 days after the surgery. Pathological examination revealed that the nodule indicated verruca vulgaris. A recheck was performed 7 months after the surgery, which showed absence of the medial toe nail, slight turbidity in the distal part, and a flat nail bed in the area of nail absence [Figure 7]. No recurrences were observed.

Figure 7

No recurrence of the lesion was found after a follow-up period of 7 months

Subungual warts are common diseases caused by human papilloma virus infection.[1] Commonly used treatments are drugs, laser, cryotherapy, photodynamic therapy, thermotherapy, surgery and other treatments.[1234] Sometimes the treatments are ineffective due to the nails’ barrier effects. Schroeter used photodynamic therapy in a group of periungual warts and subungual warts after peeling off the keratinized tissues, and achieved 90% recovery.[3]

The patient was treated with cryotherapy 11 times, which was not associated with favorable outcomes. After removal of superficial wart bodies on the toe nail, a relatively large wart was found in the deep nail root. Surgical treatment was a better choice as the wart was nodular, large, and significantly adhered to the peripheral and deep tissues. After complete removal of the wart, another three sessions of photodynamic therapy were performed, and the wound healed, which might be associated with removal of the skin lesion seen under direct observation. The wound dressing should be 3 mm beyond the wound surface in order to avoid “subclinical infections” and “inapparent infections.”[5]

Successful treatment of this patient demonstrated that surgery with photodynamic therapy is a good treatment method for subungual warts, especially large warts.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Scientific Research Project of Jiangsu Commission of Health (BJ16007).

The Introduction Project of Clinical Expert Team in Suzhou (SZYJTD201811).

Conflicts of interest

There are no conflicts of interest.