Subungual Tumors

This piece was published in Nail Pro in September 2007.

NAIL CLINIC By Cheryl L. Branche, M. D.

Subungual Tumors
Learn to look out for these abnormalities on your clients' nails.

As a nail professional, you have the opportunity to observe the ongoing condition of your clients' nails with an informed eye. When you see an abnormality of any kind, you should think about a possible cause. While you don't need to speak about specifics, bring your observations to the client's attention and suggest that a physician check out the suspicious bump or spot. You may enable your client to benefit from the early diagnosis of a potentially debilitating disease.

For example, you can prevent unnecessary health problems through the early detection of subungual tumors. The term "subungual" refers to the location of the tumor—under the nail. Subungual tumors can be benign (noncancerous) or malignant (cancerous). In this Nail Clinic, we'll also discuss subungual tumors that are present as pigmented lesions.

Tumor Facts

• Many subungual tumors are the first signs of skin cancer, which develops largely as a result of too much sun exposure.
• Malignant melanoma, the deadliest form of skin cancer, can be present as a band of black or dark brown pigment on nails, most often seen on the thumb nail or the big toenail.
• What look like warts on the nail fold or nailbed could instead be squamous cell carci­nomas. Refer clients to their physicians.
• To protect nails, wear gloves while outside or using household chemicals, stay away from the cuticles during services and usetop coats or polishes with LUV protection.

Source: The Skin Cancer Foundation (http://www.skincancer.org/)

Benign Tumors

Several types of benign tumors exist. Subungual exostosis is a firm, tender nodule that protrudes from the distal edge of the nail, most commonly found at the medi­al edge (the side of the nail closest to the center of the body) of the big toe. The nail becomes brittle and eventually breaks or is removed. A glomus tumor is an exqui­sitely tender growth or group of blood vessels that appears as a red or purple stain at the base of the nail plate. The tumor will blanch (turn white) if you press on the nail bed. Bleeding, ingrown nails and abnormalities of the nail plate are symptomatic of glomus tumors. Sometimes, the tumor causes longitudinal ridging or lifting of the nail plate itself. This type of tumor is relatively uncommon, but a single tumor is more common in women; men more commonly develop multiple tumors.

Pyogenic granulomas are usually benign and form after some sort of trauma is inflicted upon the nail bed. These tumors may pres­ent as onycholysis and may cause pain. Similar tumors may form in response to medical treatments that involve certain drugs.

The subungual osteochondroma is rare. Usually slow-growing and painful, this fleshy tumor can lift the nail plate as it grows.

Keratin implantation cysts are cysts lined with keratin and most commonly occur after trauma to the nail.

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[Photo]A blue nexus, similar to ones found on the skin usually apear on the moon of the fingernail first.

[Photo]Glomus tumors can cause Ingrown nails or lifting of the nail plate.

Subungual keratocanthomas are most commonly seen in adolescents and young adults. Usually painful, they often start as small lesions that are easily seen under the edge of the nail plate.

Fibrous dermatofibromas are pain­less and tend to lift the nail plate.

The enchondroma is an uncommon, cartilage-like tumor that arises within bone. When located near the tip of the finger, the expanding tumor causes tenderness. The client may experience a swollen, club-like finger, nail deformity and abnormal pigmentation.

Acquired digital fibrokeratoma appears abruptly and enlarges rapidly; it manifests in adulthood and can become bothersome if projections of the tumor catch on clothing, the client picks at it or the nail plate becomes distorted.

Malignant Tumors

Some types of malignant and premalignant lesions involve the subungual area. Some cancers grow very slowly, while others grow quickly and cause consider­able destruction.

Squamous cell carcinoma is a slow-growing, nonaggressive, low-grade tumor that usually occurs on the hand—specifically, on the thumb or the index finger—or the big toe. Exposure to sun and X-rays, trauma, ingestion of arsenic and viruses associated with warts are thought to be causally related.

Knowing what your
client faces during
tumor treatment may
be helpful.

This condition, seen commonly in women older than 50, is usually present as a red plaque with swelling, tissues that easily bleed, drainage, ulceration, tenderness and/or nail deformity. It can be confused with a keratocanthoma. Squamous cell carcinoma may also cause infection of the nail; as a result, the tumor can be misdiagnosed as a viral condition, eczema or an infection.

Bowen's disease causes a slow-growing tumor that occurs most commonly in the first three fingers and in males between 50 and 70 years old. This appears as a plaque with a wart-like surface, and the nail may become discolored. Bleeding and drainage may suggest cancer.

Pigmented Lesions

Subungual tumors may be present as pigmented lesions. Acral lentiginous melanoma may
be present as a nail plate deformity or as a pigmented longitudinal streak. Melanomas are mosi commonly found on the thumb.

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Blue nevus and lentigo tumors may also be present as a subungual pigment. (On a black client's nails, multiple dark bands are common and not indicators of disease.) The subun­gual melanoma frequently starts as a pigmented stain on the lunula—also known as the moon—resembling a hematoma (blood) under the nail. The stain becomes a pigmented band and may cause nail splitting, nail dystrophy and a vegetating tumor that appears in later stages. Carefully observe any pig­mented spots on a client's nails; if the band widens, the pigment diffuses at its base or the pigment spreads onto the cuticle or surrounding tissues, alert your client and urge her to visit her doctor or a dermatologist.

Treatment Options

You should learn what restrictions, if any, you need to consider during nail services for clients who are undergoing tumor treatment. If your client shares her physician's diagnosis with you, know­ing what your client faces during tumor treatment may be helpful.
Surgery. If a tumor is benign, the physician may opt to remove it or not, depending on whether the growth is bothersome or if the location pres­ents difficulties. When dealing with precancerous or malignant tumors, treatment typically requires removal. Sometimes the tumor can be com­pletely removed with a biopsy, which requires no further treatment. Most surface tumors can be cut from the skin quickly and easily with a curette (an implement with a sharp, spoon-like end) combined with an electric current to control bleeding and kill remaining tumor cells. If this method is employed, the remaining scar tissue is likely to be flat and whiter than the surrounding skin. In another method of surgery called Mohs' technique, which is used mainly tor malignant tumors, the tumor is shaved off one thin layer at a time. Each layer is checked under a microscope for cancer cells until the entire growth is removed. The degree of scarring depends on the location and size of the tumor.

Cryosurgery. Extreme cold can be used to treat certain small skin cancers or tumors. Liquid nitrogen is applied to the tumor to freeze and kill abnormal cells. Once the area thaws, the dead tis­sue falls off. The client may experience pain and swelling; after the area heals, a white scar may form.

Laser therapy. Laser therapy uses a narrow beam of light to remove or destroy tumor cells. Surgeons often use lasers for tumors that involve only the outer layer of skin; after treatment, very little scarring occurs.

Radiation and chemotherapy. Malignant skin tumors respond well to radiation therapy, which uses high-energy rays to damage cancer cells and stop their growth. Radia­tion therapy may cause a rash or leave the skin dry or reddened. Abnormal skin color or texture may develop and become more noticeable as time goes on. Topical chemotherapy refers to the use of anti-cancer drugs in a cream or lotion that is applied directly to the skin over a period of time. Inflammation is common during treatment, but scarring usually doesn't occur.

Although a nail technician doesn't diagnose medical problems, you can play a vital part in every client's heath and well-being by observing her nails. Be suspicious of nail lesions and think about the conditions that may cause an unusual nail appearance. You may be the only person in your client's circle to encourage her to seek early diagnosis and treatment.

Cheryl Louise Branche is a retired M.D. living and working in New York as a consultant.

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