By Gary M. White, MD
Periungual warts are warts about the nails. They are particularly common in children who bite their nails or pick at their cuticles.
One or more verrucous papules and plaques bordering the nail are seen.
The patient must be told that any destructive treatment of the wart may result in permanent nail dystrophy. See wart for treatment ideas as well.
Cryotherapy, observation, and Candida injection may all be done.
A benign therapy which has been reported to work is to wrap the finger with duct or other occlusive tape first longitudinally and then circumferentially twice. Have the patient remove the tape in 6.5 days and leave off for 12 hours. Then reapply. Tell the patient you are trying to "smother" the wart [Cutis 1978;22;673]. Chronic warts unresponsive to therapy, especially in patients over 25 years of age, should be biopsied to rule out squamous cell carcinoma.
This destructive procedure is aggressive, but can be very effective for periungual warts. It is often performed every month. The patient must accept a significant hole that will need to fill in. Bleeding, infection, and scarring are potential sequelae. As noted above, permanent nail dystrophy may follow. The area is cleansed, then infiltrated with lidocaine (okay to use epinephrine) and then curettage performed with a disposable curette (disposable curettes are sharper than reusable). Bleeding may be controlled with aluminum chloride and light cautery. Light cryotherapy may be done after all the visible wart is removed. The patient should keep the digit covered and greasy, with e.g., Vaseline, until healed. Clean with soap and water daily.
One to several warts may be injected with either Candida or other agents to stimulate the immune system. One study [J Cutan Aesthet Surg. 2014 Oct-Dec; 7(4): 203–208] used Mycobacterium w vaccine. Twenty-eight out of 30 patients with a variety of warts including periungual were completely cleared. Their method as paraphrased is as follows: Injection was done with 0.1 ml of killed Mycobacterium w vaccine intralesionally in a single wart. Thereafter, a single injection of 0.1 ml of vaccine was given at intervals of four weeks in a single wart until there was complete resolution of the warts or a maximum of 10 injections. Treatment was stopped if there was no response after three injections."
Topical 5-FU can clear periungual warts. The 5% cream is applied nightly to each wart. Pigmentation of the nail may rarely occur (see image below) [BJD 1985;112:621].
Various lasers have been used.
Dermatol Ther. 2012 Nov-Dec;25(6):545-50
Periungual warts and onychomadesis in a child.
Topical 5-FU can induce melanosis of the nail. This child was treated with topical 5-FU for periungual warts and developed nail pigmentation near the proximal nail fold. The pigment has grown out now over several months and will soon be shed.
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