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Hi,

Had a 26yo woman in clinic with periungual inflammation, with hypergranulation tissue coming from posterior nail fold. There was also a discharge present. The distal end of the nail was attached but the proximal end of the nail appeared to be loose and moved on palpation.

Pt has been taking antibiotics (several different types) for over two months and has had positive pathology results for several bugs (?? not sure which ones).

She came to see me because the GP had recommended next course of action would be nail removal -which she wanted to avoid.
I agreed with GP's advice as I could see no cause of hypergranulation tissue other than infection, which had not responded to any of the antibiotics administered.

I have seen this previously but it has always responded to antibiotic treatment.

This is the second time the patient has suffered with this problem - nail removal was successful in treating this last time.

She is really concerned about re-occurence. Advised all the usual footwear/hoisery etc.

Should I have tried another course of action?

Any comments would be appreciated.

SRD

 

Hi SRD:
I would have done the same.

If she is getting recurrent infections at the base of the nail, the real question becomes why?
If you have ruled out obvious hallux pathomechanics, you may want to get a lateral raised hallux x-ray to rule out sub ungual exostosis.

Steve

 

Hi,
I suggest that you do a complete nail avulsion under local anaesthetic, presuming that she has no PVD or other medical condition to contraindicate this procedure being performed, and you may find she has a sub-ungual pyogenic granuloma. I had one of these recently which caused persistent infection and chronic paronychia until it was removed and the base of the lesion hyfrecated. After removal of the lesion it should be sent to histoloy of course to confirm the diagnosis and exclude malignancy. An x-ray should also be taken to exclude subungual exostosis or radio-opaque foreign body.

Cheers
Roger

 

G'Day SRD,

How detached is the proximal area of nail? If the proximal half is completely detached, it might be worth popping in a bit of local and removing the rest of the nail, and allow the lesion to heal by secondary intention. The new nails should grown back normal provided you don't disturb the nail bed too much as your remove the attached distal portion.
From another perspective, is it worth getting a biopsy of a lesion that isn't healing? A few cultures may demonstrate a fungating wound, which wouldn't necessarily respond to antibiotic therapy, anternatively it could be a malignant growth (fingers crossed it isn't).
:santa:

 

It would be helpful to know what the infecting organism is, and also to determine if there is an underlying structural pathology (eg, sub-ungual exostosis). If this is a recurrence of a previous problem, the elective nail surgery which was undertaken doesn't seem to have been a great benefit and a further PNA/TNA is unlikely to be curative either. I've come accross pyogenic granuloma but never proximally, underneath the eponychium. After working through the differential diagnosis list, whatever is left, however unusual or unlikely, would then be the probable cause(s) of the problem.