CASE OF THE MONTH - June 2016
A painful nodule on the toe
Laura Del Regno, Ketty Peris
Institute of Dermatology, Catholic University, Rome, Italy
Case presentation: a 63-year-old woman presented with an exophytic, partially ulcerated, painful nodule located on the fifth toe of the left foot (Fig. 1A). The patient referred that the lesion had arisen approximately two years earlier as a small papule on the nail bed, and in time slowly increased in size. No other cutaneous lesions could be detected on physical examination. There was no history of warts, immune-suppression or previous exposure to radiation or chemicals.
Diagnostic work up, treatment and follow up: Histological examination of a skin biopsy specimen revealed a moderately to poorly differentiate squamous cell carcinoma (SCC) showing nests of neoplastic cells deriving from the nail bed and located in the whole dermis (Fig 1B), with focal keratinization and invasion of deep structures including the bone (Fig. 1C). Total body CT scan showed bone involvement of the distal phalanx of the left foot but no visceral metastases. Surgical treatment consisted of amputation of the fifth toe. After a follow-up of 18 months, there is no evidence of recurrence or metastases (Fig. 1D).
Key message: Squamous cell carcinoma arising from the nail bed matrix and lateral skin folds is rare. It typically presents as a slow-growing, locally destructive lesion which in time may involve the underlying bone, as in our patient. Association with trauma, chronic infection and radiation has been reported. Clinical differential diagnosis may include verruca vulgaris, onycomycosis, paronychia, amelanotic melanoma and benign neoplasms, and therefore diagnosis in the early stage is crucial to provide the most conservative management.
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