Case for Diagnosis
Painful, Rapidly Growing Tumor in the Subungual Area of the First Digit of the Right Hand
Tumoración dolorosa de rápido crecimiento en la región subungueal del primer dedo de la mano derecha
M.R. Perelló-Alzamora
, M. González-de Arriba, E. Fernández-López
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Servicio de Dermatología, Hospital Universitario de Salamanca, Salamanca, Spain
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Perelló-Alzamora, M. González-de Arriba, E. Fernández-López" "autores" => array:3 [ 0 => array:4 [ "nombre" => "M.R." "apellidos" => "Perelló-Alzamora" "email" => array:1 [ 0 => "mariarosaperello@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "González-de Arriba" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Fernández-López" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Hospital Universitario de Salamanca, Salamanca, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tumoración dolorosa de rápido crecimiento en la región subungueal del primer dedo de la mano derecha" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 665 "Ancho" => 1583 "Tamanyo" => 76283 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 51-year-old man presented with a very painful, rapidly growing tumor in the subungual area of the first digit of the right hand. The lesion had first appeared a month earlier. The patient had sustained a crush injury to the same digit 20 years earlier.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed a hyperkeratotic tumor with smooth, pink edges in the subungual area of the first digit of the right hand. The tumor was very painful on palpation and was causing the nail plate to separate from the nail bed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Histopathologic examination revealed hyperkeratosis with areas of parakeratosis, epidermal hyperplasia, and a central crater containing keratin (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Eosinophilic dyskeratotic cells and lymphoplasmacytic infiltrates were also observed.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">A plain radiograph revealed a cup-shaped lytic defect in the underlying distal phalanx (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis?</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Subungual keratoacanthoma</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Course and Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">The diagnosis was confirmed histologically. Because the site of the tumor affected the patient's ability to pinch with his thumb and index finger, we chose to treat him conservatively. The patient received 2 local infiltrations of methotrexate (20<span class="elsevierStyleHsp" style=""></span>mg/mL) with a 1-week interval between doses. Tumor regression was achieved, allowing the residual lesion to be treated with simple curettage. After 8 months of follow-up, the patient showed no signs of local recurrence or disease progression and partial reossification of the bone defect was observed in serial radiographs.</p></span></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Subungual keratoacanthoma is a rare, aggressive form of keratoacanthoma that was first described by Fisher<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> en 1961. Most common in middle-aged men,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> the disease presents as a painful, hyperkeratotic tumor on the distal phalanx of a finger, in most cases the thumb.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Characteristically, the tumor grows rapidly<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and causes destruction of the underlying bone. Subungual keratoacanthoma is often preceded by a history of trauma,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> as in the case of our patient.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Unlike common keratoacanthoma, subungual keratoacanthoma affects hairless skin, lacks epithelial cords,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> tends to invade deep tissues, and rarely regresses spontaneously.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> These characteristics explain why some authors consider subungual keratoacanthoma to be a low-grade variant of squamous cell carcinoma.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Radiographic manifestations include the cup-shaped erosion of the underlying bone without sclerosis or periosteal reaction.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This lytic defect of the distal phalanx appears in the early stages of the disease<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> and is more attributable to compression by the tumor than to infiltration by the tumor of adjacent structures.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Diagnosis is confirmed by histologic findings that reveal epidermal hyperkeratosis, parakeratosis, and a central crater containing keratin. The presence of eosinophilic dyskeratotic cells is essential.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The differential diagnosis should include squamous cell carcinoma,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> carcinoma cuniculatum, and common warts.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The first-line treatment is conservative surgery,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> which spares underlying bone tissue. Amputation should be reserved for cases that are recurrent or have a poor prognosis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Other treatments with a good response rate include methotrexate, which can be administered either systemically or, as in the case of our patient, by local infiltration. The use of local 5-fluorouracil has been associated with modest improvement.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion, we present the case of a patient with subungual keratoacanthoma to highlight the importance of suspecting this entity in patients with painful, rapidly growing, destructive subungual tumors that affect soft tissues and underlying bones. Our patient responded well to local infiltration of methotrexate. This treatment can be used as an alternative or adjuvant therapy to conservative surgery.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Additional Tests" ] 4 => array:3 [ "identificador" => "sec0025" "titulo" => "Diagnosis" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0030" "titulo" => "Subungual keratoacanthoma" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Clinical Course and Treatment" ] ] ] ] ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Comment" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Perelló-Alzamora MR, et al. Tumoración dolorosa de rápido crecimiento en la región subungueal del primer dedo de la mano derecha. Actas Dermosifiliogr. 2013;104:347–8.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 665 "Ancho" => 1583 "Tamanyo" => 76283 ] ] ] 1 => array:6 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 686 "Ancho" => 1167 "Tamanyo" => 50762 ] ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1127 "Ancho" => 1684 "Tamanyo" => 329501 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Hematoxylin-eosin, original magnification ×20. B, Hematoxylin-eosin, original magnification ×100.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Distinctive, destructive, digital disease: follow-up" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.A. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 10 | 14 | 24 |
| 2024 Octubre | 86 | 45 | 131 |
| 2024 Septiembre | 64 | 32 | 96 |
| 2024 Agosto | 113 | 70 | 183 |
| 2024 Julio | 83 | 36 | 119 |
| 2024 Junio | 169 | 31 | 200 |
| 2024 Mayo | 101 | 37 | 138 |
| 2024 Abril | 97 | 21 | 118 |
| 2024 Marzo | 81 | 40 | 121 |
| 2024 Febrero | 62 | 36 | 98 |
| 2024 Enero | 62 | 31 | 93 |
| 2023 Diciembre | 62 | 39 | 101 |
| 2023 Noviembre | 80 | 35 | 115 |
| 2023 Octubre | 89 | 35 | 124 |
| 2023 Septiembre | 99 | 39 | 138 |
| 2023 Agosto | 46 | 33 | 79 |
| 2023 Julio | 61 | 43 | 104 |
| 2023 Junio | 51 | 36 | 87 |
| 2023 Mayo | 60 | 41 | 101 |
| 2023 Abril | 39 | 48 | 87 |
| 2023 Marzo | 36 | 35 | 71 |
| 2023 Febrero | 41 | 35 | 76 |
| 2023 Enero | 45 | 46 | 91 |
| 2022 Diciembre | 45 | 68 | 113 |
| 2022 Noviembre | 45 | 36 | 81 |
| 2022 Octubre | 37 | 39 | 76 |
| 2022 Septiembre | 36 | 50 | 86 |
| 2022 Agosto | 36 | 36 | 72 |
| 2022 Julio | 30 | 35 | 65 |
| 2022 Junio | 26 | 33 | 59 |
| 2022 Mayo | 47 | 46 | 93 |
| 2022 Abril | 54 | 40 | 94 |
| 2022 Marzo | 47 | 61 | 108 |
| 2022 Febrero | 48 | 40 | 88 |
| 2022 Enero | 68 | 37 | 105 |
| 2021 Diciembre | 30 | 35 | 65 |
| 2021 Noviembre | 61 | 52 | 113 |
| 2021 Octubre | 50 | 57 | 107 |
| 2021 Septiembre | 27 | 40 | 67 |
| 2021 Agosto | 53 | 40 | 93 |
| 2021 Julio | 25 | 33 | 58 |
| 2021 Junio | 29 | 44 | 73 |
| 2021 Mayo | 30 | 33 | 63 |
| 2021 Abril | 45 | 41 | 86 |
| 2021 Marzo | 62 | 26 | 88 |
| 2021 Febrero | 36 | 33 | 69 |
| 2021 Enero | 22 | 19 | 41 |
| 2020 Diciembre | 26 | 17 | 43 |
| 2020 Noviembre | 23 | 13 | 36 |
| 2020 Octubre | 21 | 18 | 39 |
| 2020 Septiembre | 22 | 13 | 35 |
| 2020 Agosto | 28 | 16 | 44 |
| 2020 Julio | 27 | 13 | 40 |
| 2020 Junio | 41 | 24 | 65 |
| 2020 Mayo | 30 | 11 | 41 |
| 2020 Abril | 27 | 24 | 51 |
| 2020 Marzo | 26 | 19 | 45 |
| 2020 Febrero | 7 | 4 | 11 |
| 2020 Enero | 2 | 3 | 5 |
| 2019 Diciembre | 5 | 0 | 5 |
| 2019 Noviembre | 1 | 3 | 4 |
| 2019 Octubre | 2 | 5 | 7 |
| 2019 Septiembre | 7 | 1 | 8 |
| 2019 Agosto | 1 | 0 | 1 |
| 2019 Julio | 2 | 7 | 9 |
| 2019 Junio | 3 | 4 | 7 |
| 2019 Mayo | 2 | 12 | 14 |
| 2019 Abril | 1 | 9 | 10 |
| 2019 Marzo | 3 | 9 | 12 |
| 2019 Febrero | 1 | 5 | 6 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 3 | 0 | 3 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 4 | 0 | 4 |
| 2018 Septiembre | 5 | 1 | 6 |
| 2018 Julio | 0 | 1 | 1 |
| 2018 Marzo | 0 | 1 | 1 |
| 2018 Febrero | 41 | 3 | 44 |
| 2018 Enero | 44 | 4 | 48 |
| 2017 Diciembre | 49 | 6 | 55 |
| 2017 Noviembre | 43 | 1 | 44 |
| 2017 Octubre | 30 | 6 | 36 |
| 2017 Septiembre | 46 | 3 | 49 |
| 2017 Agosto | 71 | 7 | 78 |
| 2017 Julio | 45 | 5 | 50 |
| 2017 Junio | 75 | 12 | 87 |
| 2017 Mayo | 54 | 5 | 59 |
| 2017 Abril | 41 | 11 | 52 |
| 2017 Marzo | 56 | 25 | 81 |
| 2017 Febrero | 29 | 11 | 40 |
| 2017 Enero | 40 | 4 | 44 |
| 2016 Diciembre | 49 | 5 | 54 |
| 2016 Noviembre | 72 | 7 | 79 |
| 2016 Octubre | 92 | 20 | 112 |
| 2016 Septiembre | 115 | 12 | 127 |
| 2016 Agosto | 74 | 6 | 80 |
| 2016 Julio | 38 | 6 | 44 |
| 2016 Junio | 7 | 10 | 17 |
| 2016 Mayo | 4 | 10 | 14 |
| 2016 Abril | 8 | 1 | 9 |
| 2016 Marzo | 5 | 12 | 17 |
| 2016 Febrero | 14 | 10 | 24 |
| 2016 Enero | 10 | 7 | 17 |
| 2015 Diciembre | 6 | 1 | 7 |
| 2015 Noviembre | 31 | 11 | 42 |
| 2015 Octubre | 26 | 8 | 34 |
| 2015 Septiembre | 18 | 1 | 19 |
| 2015 Agosto | 10 | 4 | 14 |
| 2015 Julio | 102 | 119 | 221 |
| 2015 Junio | 87 | 10 | 97 |
| 2015 Mayo | 95 | 18 | 113 |
| 2015 Abril | 28 | 5 | 33 |
| 2015 Marzo | 44 | 7 | 51 |
| 2015 Febrero | 49 | 5 | 54 |
| 2015 Enero | 39 | 1 | 40 |
| 2014 Diciembre | 44 | 3 | 47 |
| 2014 Noviembre | 42 | 3 | 45 |
| 2014 Octubre | 51 | 4 | 55 |
| 2014 Septiembre | 33 | 1 | 34 |
| 2014 Agosto | 30 | 5 | 35 |
| 2014 Julio | 28 | 4 | 32 |
| 2014 Junio | 45 | 4 | 49 |
| 2014 Mayo | 51 | 9 | 60 |
| 2014 Abril | 39 | 5 | 44 |
| 2014 Marzo | 42 | 8 | 50 |
| 2014 Febrero | 35 | 4 | 39 |
| 2014 Enero | 32 | 4 | 36 |
| 2013 Diciembre | 37 | 10 | 47 |
| 2013 Noviembre | 21 | 4 | 25 |
| 2013 Octubre | 24 | 3 | 27 |
| 2013 Septiembre | 22 | 2 | 24 |
| 2013 Agosto | 20 | 4 | 24 |
| 2013 Julio | 9 | 1 | 10 |
| 2013 Junio | 3 | 3 | 6 |
| 2013 Mayo | 4 | 2 | 6 |
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