Management of ungual warts

Diagnosis and management of subungual and periungual verruca: A clinical review

Nail unit verruca is the most common nail tumor encountered in clinical practice and may be highly distressing to patients due to reduced functionality, cosmesis, and stigmatization. Subungual and periungual verrucae present a challenge for treatment compared to cutaneous warts of other sites and recurrence rates are high. The risk of spread to other skin and mucosal areas inherent to all warts may be increased given location on the fingertips. There are a multitude of therapeutic options, and treatment is individualized based on patient characteristics, anatomic location, number of verrucae, and size of verrucae. Destructive techniques, if used too aggressively, can permanently damage the nail matrix. In this clinical review, nail unit verruca epidemiology, pathogenesis, clinical features, treatments, and therapeutic approaches to various patient populations, including pediatric and immunosuppressed patients, are described.

A Case of Subungual Exostosis Mimicking Verruca Vulgaris

Subungual exostosis is a benign bone tumor causing nail deformities and possibly pain for the patient. Etiology includes trauma, infection, and activation of a cartilaginous cyst, more commonly seen in adult patients. Here, we present a case of subungual exostosis in a pediatric patient that initially mimicked subungual verruca vulgaris. After failed cryotherapy, surgical management allowed for symptom resolution without recurrence. This case highlights the need to consider subungual exostosis in the differential when managing suspected verruca vulgaris associated with the nail unit, a common finding in pediatric patients, particularly if the lesions are refractory to traditional verruca treatments.

Imaging features for the evaluation of skin and nail infections

Clinical manifestations of dermatological and musculoskeletal conditions can sometimes overlap, leading to confusion in diagnosis. Patients with nail and skin infections may undergo imaging examinations with suspicions of muscle, tendon, or joint injuries. Dermatological infections often involve soft tissues and musculoskeletal structures, and their etiology can range from fungi, bacteria, viruses, to protozoa. Relying solely on physical examination may not be sufficient for accurate diagnosis and treatment planning, necessitating the use of complementary imaging exams. The objective of this paper is to present and discuss imaging findings of the main infectious conditions affecting the nail apparatus and skin. The paper also highlights the importance of imaging in clarifying diagnostic uncertainties and guiding appropriate treatment for dermatological conditions.

[Common nail diseases in children and adolescents : Recognize, advise, treat]

There are a number of nail diseases that primarily occur in children and adolescents. Many of these nail changes are physiologic and are only transient. Thus, they do not need any therapy. Infectious nail diseases or nail involvement in chronic inflammatory dermatoses can be found in both children and adults, and may require specific treatment. Nail pigmentation such as longitudinal melanonychia occur significantly less frequently in children than in adult patients, and have different causes and a better prognosis. Knowledge about these child-specific peculiarities of nail diseases is necessary in order to provide the best possible advice to parents and to offer appropriate treatment. This article focuses on the most common and important nail diseases in children and adolescents and their treatment.

Consideration of underlying immunodeficiency in refractory or recalcitrant warts: A review of the literature

Although the exact mechanisms have yet to be elucidated, it is clear that cellular immunity plays a role in clearance of human papillomavirus (HPV) infections as it relates to the development of warts. Patients with extensive, recalcitrant, or treatment‐refractory warts may have an underlying immune system impairment at the root of HPV susceptibility. Early recognition of genetic disorders associated with immunologic defects that allow for recalcitrant HPV infection may expedite appropriate treatment for patients. Early recognition is often pivotal in preventing subsequent morbidity and/or mortality that may arise from inborn errors of immunity, such as WHIM (Warts, Hypogammaglobulinemia, Infections, Myelokathexis) syndrome. Among these, cervical cancer is one of the most common malignancies associated with HPV, can be fatal if not treated early, and is seen more frequently in patients with underlying immune deficiencies. A review of diseases with susceptibility to HPV provides clues to understanding the pathophysiology of warts. We also present diagnostic guidance to facilitate the recognition of inborn errors of immunity in patients with extensive and/or recalcitrant HPV infections.

Bacterial and Viral Infections of the Nail Unit

Bacterial and viral infections of the nail unit are very common as primary infections, especially bacterial paronychia and warts, but they can also be superinfections complicating other nail disorders. In many nail unit infections, the clinical presentation is nonspecific: in these cases, diagnostic tests are mandatory before treatment, to avoid spread of the infection and drug resistance. The most common forms of bacterial and viral infections that may affect the nail unit are herein described in detail, with diagnostic and treatment options provided.

Efficacy and Safety of Intralesional Bleomycin in the Management of Ungual Warts

INTRODUCTION

Ungual warts are common fibroepithelial tumours of the nail unit caused by human papillomavirus. Although various treatment modalities are available, their management is challenging due to high potential for recurrence and treatment-related nail dystrophy.

OBJECTIVE

This study evaluates the efficacy and safety of intralesional bleomycin injections in the treatment of ungual warts.

METHODS

Medical records of 80 patients with ungual warts, treated by us from 2015 to 2019, were analysed retrospectively with respect to the number of warts, site, morphology, and treatment outcome. Children <5 years of age, and pregnant and lactating women were excluded. All ungual warts were treated with intralesional injections of bleomycin 3 Units/mL, given at 3-4 weeks interval.

RESULTS AND CONCLUSIONS

A total of 250 periungual and subungual warts were treated in 80 patients. An average of 2.61 sessions per patient was required for complete resolution. Moderate pain was reported by 65 patients (81.2%), and transitory perilesional hyperpigmentation was observed in 155 lesions (62%). Severe pain and necrosis developed in 3 lesions (1.2%) that were reversible without any residual scarring and deformity. We conclude that intralesional bleomycin is an effective and safe therapeutic modality for ungual warts.

Mycobacterium bovis and you: A comprehensive look at the bacteria, its similarities to Mycobacterium tuberculosis, and its relationship with human disease

While Mycobacterium tuberculosis is the primary cause of tuberculosis in people, multiple other mycobacteria are capable of doing so. With the World Health Organization's goal of a 90% reduction in tuberculosis by 2035, all tuberculous mycobacteria need to be addressed. Understanding not only the similarities, but importantly the differences between the different species is crucial if eradication is ever to be achieved. Mycobacterium bovis, while typically thought of as a disease of cattle, remains a possible source of human infection worldwide. Although this species' genome differs from Mycobacterium tuberculosis by only 0.05%, significant differences are present, creating unique challenges to address. This review focuses on features which distinguish this bacterium from Mycobacterium tuberculosis, including differences in origin, structure, environmental persistence, host preferences, infection and disease, host immune response, diagnostics and treatment.

Current trends in needle-free jet injection: an update

Background

Jet injection can be defined as a needle-free drug delivery method in which a high-speed stream of fluid impacts the skin and delivers a drug. Despite 75 years of existence, it never reached its full potential as a strategic tool to deliver medications through the skin.

Objective

The aim of this review was to evaluate and summarize the evolution of jet injection intradermal drug delivery method including technological advancements and new indications for use.

Methods

A review of the literature was performed with no limits placed on publication date.

Results

Needleless injectors not only reduce pain during drug delivery but also confine the drug more evenly in the dermis. Understanding skin properties of the injection site is a key factor to obtain optimal results as well as setting the right parameters of the jet injector. Until the advent of disposable jet injectors/cartridges, autoclaving of the injector remains the only reliable method to eliminate the risk of infection. Needle-free intradermal injection using corticosteroids and/or local anesthetics is well documented with promising indications being developed.

Limitations

Limitations of the review include low-quality evidence, small sample sizes, varying treatment parameters, and publication bias.

Conclusion

New developments may help reconsider the use of jet injection technology. Future studies should focus on measurable optimized parameters to insure a safe and effective outcome.

Human Papillomavirus Laboratory Testing: the Changing Paradigm

High-risk human papillomaviruses (HPVs) cause essentially all cervical cancers, most anal and oropharyngeal cancers, and some vaginal, vulvar, and penile cancers. Improved understanding of the pathogenesis of infection and the availability of newer tests are changing the approach to screening and diagnosis. Molecular tests to detect DNA from the most common high-risk HPVs are FDA approved for use in conjunction with cytology in cervical cancer screening programs. More-specific tests that detect RNA from high-risk HPV types are now also available. The use of molecular tests as the primary screening tests is being adopted in some areas. Genotyping to identify HPV16 and -18 has a recommended role in triaging patients for colposcopy who are high-risk HPV positive but have normal cytology. There are currently no recommended screening methods for anal, vulvar, vaginal, penile, or oropharyngeal HPV infections. HPV testing has limited utility in patients at high risk for anal cancer, but p16 immunohistochemistry is recommended to clarify lesions in tissue biopsy specimens that show moderate dysplasia or precancer mimics. HPV testing is recommended for oropharyngeal squamous cell tumors as a prognostic indicator. Ongoing research will help to improve the content of future guidelines for screening and diagnostic testing.

Nail Disease for the Primary Care Provider

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.

Persistent toenail onycholysis associated with Beta-papillomavirus infection of the nail bed

Onycholysis, separation of the nail plate from the nail bed, is etiologically classified as primary (idiopathic) or secondary (eg, caused by psoriasis, squamous cell carcinoma). Repetitive microtrauma plays a role in idiopathic onycholysis and also facilitates human papillomavirus (HPV) infection. Herein, we report a case of persistent primary onycholysis associated with repetitive trauma and infection by a multiplicity of Beta-papillomavirus (Beta-PV) genotypes. An otherwise healthy 27-year-old woman presented with a 6-year history of onycholysis of the halluces and right second toe. Her occupation required wearing steel-toed boots. Fungal cultures were negative and antifungal therapy was ineffective. Punch biopsy of the hallux nail bed revealed epidermal hyperplasia, acanthosis, hypergranulosis, hyperkeratosis, and regions of koilocytosis without significant inflammation. This histopathology implicated chronic irritation and HPV infection. Immunohistochemistry demonstrated productive HPV infection. Nested PCR using degenerate consensus primers revealed infection with 5 known and 1 novel Beta-PV genotypes (HPV 5, HPV 8, HPV 20, HPV 23, HPV 37, and FA25). The histopathology of primary onycholysis is unknown. Based on the aforementioned, we propose that repetitive microtrauma caused by wearing steel-toed boots promoted onycholysis and HPV infection, the latter of which, altered the differentiation of nail bed epithelium, preventing adhesion of nail plate to the nail bed. Lastly, the presence of oncogenic Beta-PV genotypes (ie, HPV 5, 8, and 20) implicates a risk for subungual squamous cell carcinoma, particularly if the nail remains symptomatic and persistently irritated.