Subungual Corn: a tender pigmented subungual lesion in older people

NewsBot · Feb 6, 2014

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Subungual Corn: a tender pigmented subungual lesion in older people.
R Deberker DA, Wlodek C, Bristow IR.
Br J Dermatol. 2014 Feb 1

BACKGROUND:
In the podiatric literature, corns are also referred to as heloma and are divided into 3 types - heloma durum, molle and miliare. Clinically, heloma durum refers to hard areas at sites of friction, heloma molle to soft areas between toes that rub against each other and heloma miliare to "seeds" of hard skin on the sole of the foot.
OBJECTIVES:
To define and report a variant of heloma durum that is not referenced in the peer review literature. It occurs as a tender mass in the distal nail bed beneath the big toenail in older women. The entity is rarely recognised for what it is. Instead it is typically provisionally diagnosed as a possible malignancy given the associated pain and haemorrhage within it.
METHODS:
This was a retrospective study whereby the records, including photographs, of all cases of subungual corn were reviewed. All the patients were seen in an outpatient setting in a teaching hospital with a service with a specialist interest in nail pathology provided by a single physician.
RESULTS:
There were a total of 16 patients (15 females) [mean age 68 years (49-87)]. All patients reported discomfort under the big toe nail. 12 patients also had associated subungual haemorrhage. The right big toe nail was involved in 10/16 patients. The history was between 6 and 30 months and none of the patients had received effective treatment. Mycology was negative where undertaken in primary care. The shared clinical features were of a subungual focus of hyperkeratosis (100%) with haemorrhage admixed in 75% of cases. The lesion was located in the midline third of the nail in 11/16 cases (69%). In all instances the affected distal margin of nail was the uppermost point in the lateral profile of the toe. Hyperextension at the distal interphalangeal joint of the affected toe could be clinically demonstrated with the patient standing. Where patients came with older shoes, it was possible to demonstrate the impact changes of the distal toe on the uppers of the shoe. Where diagnosis was not clear, in 8 cases, local excision was performed. In the remainder of cases simple clearance of the keratin plug was provided by employing a V shaped technique whilst clipping the nail. All patients were advised to have podiatric follow up for advice on foot care and foot wear to avoid relapse. Where patients were followed up for more than 6 months (n=7) there was no relapse.
CONCLUSION:
Subungual corns can be misdiagnosed as exostoses, viral warts and squamous cell carcinomas. The benign and curable nature of the subungual corn can be demonstrated within clinic, through clinical explanation and paring down. This should be attempted for lesions with these features in order to avoid surgery at this poor healing site in the elderly with potential for peripheral ischaemia. This article is protected by copyright. All rights reserved.
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