See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/235398892 Subungual Vascular Malformation with Unusual Presentation Article in Journal of Cutaneous and Aesthetic Surgery · October 2012 DOI: 10.4103/0974-2077.104921 · Source: PubMed CITATIONS READS 4 66 1 author: Uwe Wollina Städtisches Klinikum Dresden 2,507 PUBLICATIONS 13,787 CITATIONS SEE PROFILE Some of the authors of this publication are also working on these related projects: Cutaneous T-Cell lymphoma View project History of Dermatology & Bioethics View project All content following this page was uploaded by Uwe Wollina on 31 December 2014. The user has requested enhancement of the downloaded file.
JCAS_75_12R6 LETTERS 1 1 2 2 Subungual Vascular Malformation with Unusual Presentation 3 3 4 4 5 5 6 6 7 7 Sir, to the tissue of the proximal nail fold. After incision of 8 8 The nail unit is a highly specialized structure of skin. the proximal fold and further meticulous preparation, the 9 9 Certain tumours and other complaints prefer this unique tumour could be completely surgically removed leaving 10 10 organ. the proximal matrix untouched [Figures 2b and c]. The 11 11 remaining nail plate was sutured in the midline as a 12 12 We observed a 71‑year‑old male who presented with a protective shield of the wound bed [Figure 2c]. We 13 13 slowly progressive longitudinal ridge‑like thickening of performed antibiotic prophylaxis with 2 × 500 mg/ d 14 14 the nail plate of his left thumb [Figure 1]. Under pressure cefuroxim. Healing was unvenetful [Figure 2d]. 15 15 the lesion was a bit painful. The nail plate thickening 16 16 was restricted to the ventral layer adjacent to the nail Histopathological investigation revealed an angiomatous 17 17 bed, whereas the visible dorsal surface was unaffected. malformation composed of venous and arterial vessels 18 18 Our primary suspicions were onychomatrixoma, [Figures 3a and b]. The diagnosis of an acquired digital 19 19 onychopapilloma, or glomus tumour. arterio‑venous malformation (ADAVM) was made. 20 20 21 21 We performed nail surgery with a proximal fjnger block ADAVM is a rare condition occurring either as inherited 22 22 using 1% xylocaine. The plate was cut longitudinally or acquired type. Characteristically there is an abnormal 23 23 along the ridge. Then we removed the thickened part connection between arterioles and venules of the 24 24 starting from underneath the proximal nail fold by the fjnger fed by the digital vessels. [1,2] The most common 25 25 help of a nail elevator [Figure 2a]. A soft tissue tumour presentation of ADAVM is small, slightly raised dark‑red 26 26 was found in the lateral part of the lunula that extended macules on the distal parts of fjngers. The subungual 27 27 occurrence has not been reported before. [1‑4] 28 28 29 29 This makes our case unique. The lunula is a whitish 30 30 half‑moon shaped structure known for a poor 31 31 vascularisation compared to other parts of the nail 32 32 organ. Magnetic resonance imaging (MRI) investigations 33 33 have shown a loose connective tissue with reticular 34 34 and subdermal vascular networks that develop larger 35 35 meshes. [5,6] This can dramatically change in case of 36 36 trauma or systemic infmammation. [7,8] We suppose that 37 37 trauma might have been responsible for ADAVM in 38 38 our patient. 39 39 40 40 Treatment for finger tip ADAVM can be realized 41 41 by neodymium: Yttrium‑aluminium‑garnet laser 42 42 or surgery. [7,8] Surgery was preferred in our case 43 43 with unusual presentation supporting histological Figure 1: Lateral subungual longitudinal thickening of the 44 44 examination. nail plate 45 45 46 46 47 47 48 48 49 49 50 50 51 51 52 52 a c b d 53 53 Figure 2: Surgery of the nail. (a) Partial avulsion of the nail plate. In the proximal nail bed a soft tumour is visible. (b) Complete 54 54 excision of the proximal nail bed tumour. Thereafter, a longitudinal cut was made to remove the remaining part of the tumor 55 55 underneath the proximal nail fold. (c) Suturing of the proximal nail fold and use of nail plate as a protective shield. (d) Two 56 56 weeks later with uncomplicated healing 289 Journal of Cutaneous and Aesthetic Surgery - Oct-Dec 2012, Volume 5, Issue 4
Letters 1 malformation: Clinical, dermoscopy, ultrasound and histological study. 1 Eur J Dermatol 2012;22:138‑9. 2 2 3. Bekhor PS, Ditchfield MR. Acquired digital arteriovenous malformation: 3 3 Ultrasound imaging and response to long‑pulsed neodymium: 4 4 Yttrium‑aluminium‑garnet treatment. J Am Acad Dermatol 2007;56:S122‑4. 5 5 4. Kadono T, Kishi A, Onishi Y, Ohara K. Acquired digital arteriovenous 6 6 malformation: A report of six cases. Br J Dermatol 2000;142:362‑5. 7 7 5. Wolfram‑Gabel R, Sick H. Vascular networks of the periphery of the a fingernail. J Hand Surg Br 1995;20:488‑92. 8 b 8 6. Drapé JL, Wolfram‑Gabel W, Idy‑Peretti I, Baran R, Goettmann S, Sick H, 9 Figure 3: Histopathological findings: (a) Haematoxylin- 9 et al . The lunula: A magnetic resonance imaging approach to the subnail stained tissue samples with dilated vessels. (b) Elastica- 10 10 matrix area. J Invest Dermatol 1996;106:1081‑5. stain demonstrates elastic fjbres in thickened vessel walls 11 11 7. Richert B, Di Chilacchio N, Haneke E. Nail Surgery. London, New York: corresponding to arterial vessels (a and b - ×10) 12 12 Informa Healthcare; 2010. 13 13 8. Wollina U, Barta U, Uhlemann C, Oelzner P . Lupus erythematosus‑associated Uwe Wollina, 14 red lunula. J Am Acad Dermatol 1999;41:419‑21. 14 AQ1 15 15 Department of Dermatology and Allergology, ???, Dresden, Germany 16 Access this article online 16 E‑mail: uwollina@web.de Quick Response Code: 17 17 Website: 18 REFERENCES 18 www.jcasonline.com 19 19 1. Yang CH, Ohara K. Acquired digital arteriovenous malformation: 20 20 A report of three cases and study with epiluminescence microcopy. DOI: 21 21 Br J Dermatol 2002;147:1007‑11. *** 22 22 2. Cuesta Montero L, Soro P, Bañuls J. Acquired digital arteriovenous 23 23 24 24 25 25 26 26 Author Queries??? 27 27 AQ1: Kindly confjrm authors names, and provide 28 28 complte affjliations 29 29 30 30 31 31 32 32 33 33 34 34 35 35 36 36 37 37 38 38 39 39 40 40 41 41 42 42 43 43 44 44 45 45 46 46 47 47 48 48 49 49 50 50 51 51 52 52 53 53 54 54 55 55 56 56 290 Journal of Cutaneous and Aesthetic Surgery - Oct-Dec 2012, Volume 5, Issue 4 View publication stats View publication stats
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