Periungual Warts


Periungual Warts

Primary Care Visit Report   

A 32-year-old male with no past medical history presented with redness, scaling, and induration around his fingernails for 1 year. He had previously been prescribed terbinafi ne cream, which improved the redness but the periungual rash persisted. 

Vitals were normal. On exam, verrucous, well-demarcated, skin-colored to lightly pigmented papules and erythema were present on the periungual areas of all digits. Some induration and scaling was noted. 

 The differential considered was warts (or  verrucae  ) alone versus verrucae accom-panied by fungal involvement as the patient reported improvement with terbinafi ne. The patient was referred to dermatology for further evaluation.  

    Discussion from Dermatology Clinic 

     Differential Dx   

    Periungual warts  

  Acquired periungual fi brokeratoma

  Lichen planus  



  Periungual  callus    

  Squamous cell carcinoma     

     Favored Dx   

 Some of the patient’s lesions feature the dark, central puncta typical of common warts. The appearance and history is consistent with verrucous lesions.  


 Cutaneous warts are more prevalent in men than women. The median affected age in both genders is during the third decade, but prevalence peaks in school-age years. Palms and feet are the most commonly affected sites although they can occur any-where on the body [ 1 ]. Warts may appear more frequently in immunosuppressed populations, such as organ transplant recipients, or those with HIV infections, and demonstrate more extensive involvement and recalcitrance in those cases. 

  Cutaneous warts   are caused by  human papillomavirus  . Over 150 different strains have been identifi ed, but HPV 1, 2, 4, 7, 27, 57, and 65 appear to be frequently linked with cutaneous warts [ 2 ,  3 ]. Rarely, types 16 and 18 can cause periungual warts and are considered high risk for transforming into squamous cell carcinoma.  


  Periungual warts   are warts that appear adjacent to nails of the hands and feet. Warts typically present as small, rough, caulifl ower-like papules. Black puncta, tiny dots representing blood vessels, often appear at the center of the hyperkeratotic, dome- shaped lesions. These may also cause pinpoint bleeding if the growth is shaved down. Warts in children may resolve spontaneously over a period of several months to a year, while they may persist for several years in adults.  


 Clinical examination is usually sufficient for diagnosis.  Biopsy   should be performed in immunocompromised patients, or in recalcitrant, long-standing warts to rule out high risk strains of HPV, Bowen’s disease, and squamous cell carcinoma [ 4 ].  


 The approaches to wart treatment include topical, intralesional, and laser therapies. Surgical options include electrodesiccation, a tissue destruction technique using electrical current, and excision but are not fi rst-line due to risk of scarring and the likelihood of recurrence [ 5 ]. The elected therapy should take into account patient age and immunity, tolerance for discomfort, lesion size and number, and desired speed to resolution. 

  Cryotherapy   with liquid nitrogen is a very common and successful approach to therapy. It can be directly sprayed or applied with a cotton tipped applicator, depending on patient age, as younger children may have diffi culty tolerating extensive spraying, and location of lesion. Clearance rates can be as high as 85 % and perhaps higher when warts are pared down to get rid of thickened, dead skin prior to freezing [ 6 ,  7 ]. Spray should be applied at a 90° angle, 1–2 cm away from the skin. Frost can be achieved by spraying continuously for about 4–5 s then allowing the skin to thaw for about 10 s. This freeze thaw cycle should be repeated 2–3 times per visit. Treatment may require several sessions before the wart resolves. In our practice, we average three treatment sessions. 

 Topical 50 % salicylic acid has a lower clearance rate at approximately 24 % and thus does not appear to be more effective than  cryotherapy      [ 7 ,  8 ]. It may be used for patients desiring a more conservative treatment approach. Imiquimod 5 % cream is an immune response modifi er than may be successful when used as a  combination therapy   with salicylic acid or other destruction methods (e.g., paring, cryotherapy), but unlikely to produce complete clinical clearance on its own [ 9 ]. 

 Intralesional candida antigen causes upregulation of immune responses which are thought to then target warts.  Candida   injections have been found to achieve clearance in 74 % of patients, and are particularly useful in recalcitrant warts [ 3 ]. Candida injections can cause local erythema and pruritus. Intralesional bleomycin injections at a concentration of 1 mg/ml demonstrated complete resolution without recurrence after a year in one study [ 10 ].  Bleomycin   works as a chemotherapeutic agent that interferes with the reproduction of viral cells. Injections should not be administered more than two times per site over the course of treatment in order to avoid risk of local necrosis and Raynaud’s disease. 

 Patients may be referred to a dermatologist for treatment with  pulsed dye laser (PDL)  . PDL targets the microvasculature that supplies verrucous growths. When the blood supply is eliminated, the warts become necrotic and eventually fall off. PDL treatment is advantageous because patients do not experience much pain and there is low risk of scarring; however, clearance rates are lower, at 34 %, after an average of 2–4 treatments [ 3 ,  5 ].  


 The specifi cs of patient follow-up will depend on the course of treatment elected; however, all patients should return for reevaluation 2 weeks after initial therapy to monitor progress.  Cryotherapy   and PDL should be repeated every 2 weeks until warts have resolved. Candida and bleomycin injections may clear warts after one treatment, but warts should be monitored under a dermatoscope to confi rm no resid-ual puncta are visible. Some patients may opt to take conservative approaches like salicylic acid treatment, or occlusion under duct tape, in which case they may be instructed to return for treatment if the  warts   grow too bothersome.   

    Questions for the Dermatologist 

–  Do warts often have a superimposed fungal infection?  

 No. However, if the position of a wart is lifting the nail plate, that would predispose the area to a secondary fungal infection by improving the access of that pathogen. 

–  Do warts spread? Could this patient somehow be auto-infecting himself?  

 Yes,  warts   can spread. Viral particles can be transmitted by scratching and picking. It is common to see children who are biting or sucking warts to later develop them on their lips. 

–  What are the contact precautions, if any, for someone with warts?  

It is not necessary to isolate patients with warts. They are transmittable by prolonged skin-to-skin contact. Family members should be advised to wear sandals in the shower if the patient has plantar warts, and they should not share bath scrub brushes.

Are there any special considerations when doing cryotherapy on someone with warts on every finger? Is there a clinical indication for treating one hand at a time?

The considerations should be discussed with the patient. There is no medical reason for treating one hand at a time, but patients have varying tolerance. Some patients may want the warts gone as soon as possible. Others may not be able to tolerate extensive treatment, and would prefer to take their time treating potentially blistering lesions. 

– Are there any specifi c precautions when using cryotherapy around the nail area so as not to cause any permanent nail disfi guring? i.e., do you do cryotherapy for shorter amount of time or a lesser number of freeze thaw cycles? 

  Nail growth   comes from the nail matrix underneath the proximal nail fold. Freezing periungual warts, unless very aggressively with a wide area of tissue damage, is unlikely to impact that anatomic nail unit. With cryotherapy treatment on any region of the body, cycles with 4–5 s of continuous spraying followed by about 10 s of thawing aim to minimize tissue damage, which in turn avoids destruction of any underlying structures.     


 1.   Kyriakis K, Pagana G, Michalides C, Emmanuelides S, Palamaras I, Terzoudi S. Lifetime prevalence fluctuations of common and plane viral warts. J Eur Acad Dermatol Venereol. 2007;21(2):260–2.

 2.   De Koning MN, Quint KD, Bruggink SC, Gussekloo J, Bouwes Bavinck JN, Feltkamp MC, Quint WG, Eekhof JA. High prevalence of cutaneous warts in elementary school children and ubiquitous presence of wart-associated HPV on clinically normal skin. Br J Dermatol. 2015. doi:  10.1111/bjd.13216    . Accessed 24 Oct 2014.

 3.   Herschthal J, McLeod MP, Zaiac M. Management of ungual warts. Dermatol Ther. 2012; 25(6):545–50.

 4.   Riddel C, Rashid R, Thomas V. Ungual and periungual human papillomavirus-associated squamous cell carcinoma: a review. J Am Acad Dermatol. 2011;64(6):1147–53.

 5.   Tosti A, Piraccini BM. Warts of the nail unit: surgical and nonsurgical approaches. Dermatol Surg. 2001;27(3):235–9.

 6.   Zimmerman EE, Crawford P. Cutaneous cryosurgery. Am Fam Physician. 2012;86(12): 1118–24.

 7.   Ko J, Bigby M. Randomized controlled trial of cryotherapy with liquid nitrogen vs topical salicylic acid vs wait-and-see for cutaneous warts. Arch Dermatol. 2012;148(7):840–2.

 8.   Kwok CS, Gibbs S, Bennett C, Holland R, Abbott R. Topical treatments for cutaneous warts. Cochrane Database Syst Rev. 2012;9, CD001781.

 9.   Ahn CS, Huang WW. Imiquimod in the treatment of cutaneous warts: an evidence-based review. Am J Clin Dermatol. 2014;15(5):387–99.

    10.   Soni P, Khandelwal K, Aara N, Ghiya BC, Mehta RD, Bumb RA. Effi cacy of intralesional bleomycin in palmoplantar and periungual warts. J Cutan Aesthet Surg. 2011;4(3):188–91.   

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