Warty papule and scaling around finger

Consider CO₂ laser therapy, Mohs surgery

Various therapeutic modalities have been used for BD of the nail, including electrodesiccation and curettage, 5% fluorouracil cream (Efudex), cryosurgery, and radiotherapy. Most of these treatments have not been successful and are associated with high recurrence rates.^10-12

Simple excision of nail bed and matrix is successful in small and localized BD lesions. CO₂ laser therapy for periungual BD has been reported to have up to an 80% cure rate, with less scarring and contractures when compared with surgical excision.¹⁰ Recently, imiquimod (Aldara 5% cream) has been used with success for BD of the nail—especially recurrent disease.¹¹

Mohs surgery is considered the best treatment approach, with cure rates of up to 96%.¹² Mohs surgery allows for adequate depth of tumor resection, great preservation of normal digit function, and excellent cosmetic results, with healing by secondary intention. Although the 5-year recurrence rate after Mohs surgery is small (about 3%), it is still a good idea to follow the patient closely to assess for a potential relapse.

If invasive SCC is suspected, the patient’s regional lymph nodes should be evaluated for possible metastasis. Radiologic study of the digit(s) to assess for bone invasion should also be considered. Amputation of the affected digit, although a drastic measure, is an option if there is evidence of bone involvement.¹³

Our patient’s course. After discussing the different treatment options with our patient, we referred him to plastic surgery for wide excision. He was subsequently lost to follow up.

Correspondence
Amor Khachemoune, MD, CWS, Assistant Professor, Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 530 First Avenue, Suite 7R, New York, NY 10016; amorkh@pol.net