Surgical Treatmetn of Some Lesions of the Nail Unit (Abstract)
Edward Krull MD
Dermatology Online Journal 7(2): 21E

PRELIMINARY

Assessment of the patient

There should be a general medical assessment of the patient by history, examination and special testing if indicated. These include: diabetes, heart valve conditions, synthetic vascular replacement, joint replacement, bleeding tendencies and other conditions.

Circulatory adequacy by clinical findings, such as presence of hair on digits, quality of the skin, state of the pulses, capillary refill and dependent rubor and pallor with elevation.

Anesthesia

I prefer lidocaine without epinephrine usually 1%, 2%. Lidocaine may be more effective for digital blocks. Long-acting agents such as Marcaine may be added to reduce pain for longer periods of time. Local anesthesia, digital blocks and ring blocks may be used. Frigiderm in ice cube application reduces the initial pain. Volume of anesthesia is usually less than 2cc for local blocks and less than 3cc for digital or ring blocks.

Instruments

Specialized instruments may include Beaver handles and blades. Penrose drains as tourniquets, fine-nosed mosquito hemostats, possibly nail elevators and double action nail cutters and English nail splitters.

Dressing

Dressings vary. I prefer antibacterial ointment followed by petrolatum gauze, fine mesh gauze (Sof-wick) Kling and finished with a tubular elastic net (Se Pro'Net)

Care must be used to apply some modest pressure with the dressing, but never too tight.

LESIONS

MYXOID PSEUDOCYST (mucoid cyst, mucous cyst, ganglion cyst)

The most common location is in the proximal nail wall, but it may occur on occasion between the bone and the matrix, or within the matrix. In its most common location it produces a grooving of the nail.

Treatment

• Aspiration followed by intralesional corticosteroids
• Cryosurgery
• Single freeze versus double freeze-thaw
• Resection of part of the proximal nail fold
• Resection of mycoid pseudocyst and debridement of osteophytes of the DIP

GLOMUS TUMOR

Bluish tumor that produces lacinating, radiating pain from pressure of cold.

• Que-tip sign

• Radiologies studies

• Ultrasound

• MRI

Treatment

• Exploration technique with incision of proximal nail fold

• Transverse incision over tumor

• Resection of encapsulated tumor

BOWEN'S DISEASE OF THE NAIL UNIT

Bowen's disease of the nail unit is frequently combined with squamous cell carcinoma into the term epidermoid carcinoma, partly because some lesions of Bowen's show spots of invasive squamous cell carcinoma and because the differentiation of the two may be difficult.

Treatment

• 5-Fluorouracil

• curretage and electrosurgery

• cryosurgery

• laser

• Surgical excision

  1. )Local excision

  2. )Mohs micrographic surgery is preferred by the author

LONGITUDINAL MELANONYCHIA (LM)

Clinical aspects

• 30% of malignant melanoma of the nail unit have a preceding history of LM

• Many findings of LM and malignant melanoma are similar

• Criteria for biopsy are not well-defined.

  1. Color

  2. Width

  3. Rapidly expanding or sudden onset of LM

  4. Fuzzy borders

  5. Variegated colors

  6. Hutchinson's sign pathognomonic of malignant melanoma if other causes can be eliminted.

  7. Possibly over 50,000,000 Americans with LM; especially common

Treatment

• Biopsy-excision

  1. Methods should retain nail attachment

  2. Punch biopsy of proximal part of pigmented streak

     (a)Baran & Kechijian variation

  3. Excision of pigmented streak

© 2001 Dermatology Online Journal