When a Patient Presents With Oozing and Granulation to the Nail Bed

A 74-year-old female presented for evaluation of chronic drainage and apparent granulation tissue from the left hallux nail bed for the prior six months. She had a total matrix phenol ablation surgery just over one year prior to presentation which healed perfectly. All was fine until she developed oozing and granulation tissue in the nail bed seven months postoperatively. It did not resolve over the next five months despite oral and topical antibiotics and standard wound care. There was no trauma history to the area of concern. The patient’s medical history was non-contributory, and she denied a personal or family history of skin cancer.

The original treating podiatrist then referred the patient to a dermatologist who performed a biopsy, revealing a diagnosis of calcinosis. The patient stated that she experienced severe pain during the biopsy and felt that the toe was not adequately anesthetized, possibly resulting in an inadequate specimen. Due to the diagnosis of calcinosis, an X-ray ordered by the dermatologist revealed a subungual exostosis emanating from the distal medial aspect of the distal phalanx of the left hallux. The patient had no nail bed pain on presentation, nor before the nail bed lesion appeared. 

Upon physical examination, the patient was alert and well-oriented to time, person, and place. Pedal pulses were palpable bilaterally. Skin temperature and color were normal. Sensory examination was completely within normal limits. Hydration of the skin appeared normal, and all remaining toenails were clear. Focusing on the primary area of concern, the left hallux nail bed showed total consumption by granulation-like tissue and no sign of pigmentation (see first photo below). There was no evidence of pus or cellulitis. Review of the previously taken X-rays revealed a distal phalangeal exostosis, moderate in size (see second photo below). There was no sign of underlying osteomyelitis.

Key Questions To Consider

1. What conditions might you include in your differential diagnosis?

2. What diagnostic testing might you order for this patient?

3. After confirming the diagnosis, what further testing becomes indicated?

4. What treatment options might this patient have?

Key Components of the Diagnostic Process

The dermatologist originally referred this patient to the Mount Sinai podiatry service for removal of the exostosis. However, I advised the patient that the bony exostosis should not produce this kind of appearance and changes to the nail bed, and that I thought this was a nail bed tumor. I strongly advised another biopsy, which she agreed to.

After a hallux block of 3 cc total of lidocaine 2% plain, we then prepped and draped the area in the standard sterile fashion. We then obtained a 3 mm punch biopsy from the central nail bed and a shave specimen from the distal medial nail bed. The specimens were fixed in formalin and sent to dermatopathology for diagnosis.

The pathologic diagnosis was: squamous cell carcinoma, invasive, well-differentiated, and extending to all the margins, with adjacent calcinosis cutis.

Having confirmed the diagnosis, I referred the patient to medical oncology for staging.

A PET CT scan revealed a focus of activity in the tip of the hallux, as expected, and another focus at the first metatarsal head area, possibly secondary to degenerative changes. Due to this finding, an MRI with and without contrast revealed a better assessment of the extent of the local disease, confirming that the tumor was confined to the nail bed and that the uptake on the PET scan at the first metatarsophalangeal joint was due to arthritic changes. Based on no evidence of metastatic disease, oncology recommended complete removal of the tumor.

The patient did not want to have a distal toe amputation, so I referred her for Mohs micrographic surgery to completely resect the lesion with clear margins and application of a skin graft from the sinus tarsi donor site of the same foot. Due to the presence of the exostosis and unfamiliarity with the sinus tarsi as a donor site, the dermatologic surgeon asked me to join him for the resection.

Detailing the Surgical Course

As part of the preoperative planning on the day of surgery, the area of resection on the toe was mapped out completely (see left photo above). After multiple resections of tissue with pathologic analysis taking place in real-time, we completed the resection when histology noted all resected margins were free of tumor (see right photo above). At this time, we utilized a rongeur to resect the exostosis from the distal phalanx through a small incision into the nail bed. We then directed our attention to the sinus tarsi, where we resected an elliptical wedge of skin, subsequently defatting and fenestrating the sample, and used this as a graft over the exposed bed of the tumor resection (see bottom photo below). Lastly, we sutured the graft into place on the left hallux with chromic sutures (see left photo below). A non-adherent gauze stent dressing, sutured into place, protected the operative site (see right photo below). The patient tolerated the procedure well and without incident. We wrapped the foot with sterile gauze and dispensed a surgical shoe.

Pertinent Postoperative Points to Consider

The patient returned in one week for the first postoperative follow-up (see first photo below). At this time, the graft site appeared dry with crusts, dried blood, and a dusky appearance to some parts of the graft. There was no sign of infection. We instructed the patient to gently cleanse area daily and apply clean dressings with petroleum jelly.

The patient then returned at 8 weeks postop. The wound still exhibited crusting, but the graft appeared to take at 100 percent (see second photo below). The crusts were easily removed and we encouraged the patient to shower and wash the surgical site liberally. The patient continued with local wound care. She then provided serial photographs of her progress through telemedicine follow-up. One week later, all crusts were gone and one could note complete nail bed epithelialization (see third photo below). The final photo revealed a completely healed nail bed with total skin coverage (see fourth photo below). The patient will now have regular skin checks encompassing surveillance of the surgical site as well as total body skin exams. The patient was then encouraged to be diligent about sun protection.

Answering the Key Diagnostic Questions

1. Hypergranular tissue, occult infection, subungual exostosis causing biomechanical issues, neoplasm, and microtrauma are all included in the differential diagnoses.

2. Repeat biopsy is indicated in this case.

3. Referral to medical oncology for staging, PET CT scan, and possible MRI are all among the next steps.

4. Since there was no metastasis noted beyond the nail bed, and the patient did not wish to have a distal toe amputation, she subsequently underwent Mohs micrographic surgery for complete excision with skin from the sinus tarsi as a donor site.

In Summary

This case demonstrates the need for timely biopsy of suspicious nonhealing lesions. Once one makes a diagnosis of malignancy, appropriate staging must take place before planning any definitive surgery, as well as additional imaging depending on what the oncology evaluation reveals. If metastatic disease is detectable at the outset, the plan for definitive surgery for the primary tumor may necessitate delay or change. This underscores the need for a multidisciplinary approach for the definitive management of podiatric skin and nail malignancies after making an office-based diagnosis.

Dr. Markinson is an Associate Professor of Orthopedics and Chief of Podiatric Medicine and Surgery at the Icahn School of Medicine at Mount Sinai Medical Center in New York. He is an Adjunct Professor in the Department of Podiatric Medicine at the New York College of Podiatric Medicine.