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Subungual Vascular Malformation with Unusual Presentation

Article in Journal of Cutaneous and Aesthetic Surgery · October 2012

DOI: 10.4103/0974-2077.104921 · Source: PubMed

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1 author: 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 Uwe Wollina Städtisches Klinikum Dresden

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Journal of Cutaneous and Aesthetic Surgery - Oct-Dec 2012, Volume 5, Issue 4

289

Sir, The nail unit is a highly specialized structure of skin. Certain tumours and other complaints prefer this unique

• rgan.

We observed a 71‑year‑old male who presented with a slowly progressive longitudinal ridge‑like thickening of the nail plate of his left thumb [Figure 1]. Under pressure the lesion was a bit painful. The nail plate thickening was restricted to the ventral layer adjacent to the nail bed, whereas the visible dorsal surface was unaffected. Our primary suspicions were onychomatrixoma,

• nychopapilloma, or glomus tumour.

We performed nail surgery with a proximal fjnger block using 1% xylocaine. The plate was cut longitudinally along the ridge. Then we removed the thickened part starting from underneath the proximal nail fold by the help of a nail elevator [Figure 2a]. A soft tissue tumour was found in the lateral part of the lunula that extended to the tissue of the proximal nail fold. After incision of the proximal fold and further meticulous preparation, the tumour could be completely surgically removed leaving the proximal matrix untouched [Figures 2b and c]. The remaining nail plate was sutured in the midline as a protective shield of the wound bed [Figure 2c]. We performed antibiotic prophylaxis with 2 × 500 mg/ d

• cefuroxim. Healing was unvenetful [Figure 2d].

Histopathological investigation revealed an angiomatous malformation composed of venous and arterial vessels [Figures 3a and b]. The diagnosis of an acquired digital arterio‑venous malformation (ADAVM) was made. ADAVM is a rare condition occurring either as inherited

• r acquired type. Characteristically there is an abnormal

connection between arterioles and venules of the fjnger fed by the digital vessels.[1,2] The most common presentation of ADAVM is small, slightly raised dark‑red macules on the distal parts of fjngers. The subungual

• ccurrence has not been reported before.[1‑4]

This makes our case unique. The lunula is a whitish half‑moon shaped structure known for a poor vascularisation compared to other parts of the nail

• rgan. Magnetic resonance imaging (MRI) investigations

have shown a loose connective tissue with reticular and subdermal vascular networks that develop larger meshes.[5,6] This can dramatically change in case of trauma or systemic infmammation.[7,8] We suppose that trauma might have been responsible for ADAVM in

• ur patient.

Treatment for finger tip ADAVM can be realized by neodymium: Yttrium‑aluminium‑garnet laser

• r surgery.[7,8] Surgery was preferred in our case

with unusual presentation supporting histological examination. JCAS_75_12R6

LETTERS

Subungual Vascular Malformation with Unusual Presentation

Figure 1: Lateral subungual longitudinal thickening of the nail plate 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 excision of the proximal nail bed tumour. Thereafter, a longitudinal cut was made to remove the remaining part of the tumor underneath the proximal nail fold. (c) Suturing of the proximal nail fold and use of nail plate as a protective shield. (d) Two weeks later with uncomplicated healing

d c b a

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Journal of Cutaneous and Aesthetic Surgery - Oct-Dec 2012, Volume 5, Issue 4

290

Letters

Uwe Wollina,

Department of Dermatology and Allergology, ???, Dresden, Germany E‑mail: uwollina@web.de

REFERENCES

1. Yang CH, Ohara K. Acquired digital arteriovenous malformation: A report of three cases and study with epiluminescence microcopy. Br J Dermatol 2002;147:1007‑11. 2. Cuesta Montero L, Soro P, Bañuls J. Acquired digital arteriovenous

AQ1

malformation: Clinical, dermoscopy, ultrasound and histological study. Eur J Dermatol 2012;22:138‑9. 3. Bekhor PS, Ditchfield MR. Acquired digital arteriovenous malformation: Ultrasound imaging and response to long‑pulsed neodymium: Yttrium‑aluminium‑garnet treatment. J Am Acad Dermatol 2007;56:S122‑4. 4. Kadono T, Kishi A, Onishi Y, Ohara K. Acquired digital arteriovenous malformation: A report of six cases. Br J Dermatol 2000;142:362‑5. 5. Wolfram‑Gabel R, Sick H. Vascular networks of the periphery of the

• fingernail. J Hand Surg Br 1995;20:488‑92.

6. Drapé JL, Wolfram‑Gabel W, Idy‑Peretti I, Baran R, Goettmann S, Sick H, et al. The lunula: A magnetic resonance imaging approach to the subnail matrix area. J Invest Dermatol 1996;106:1081‑5. 7. Richert B, Di Chilacchio N, Haneke E. Nail Surgery. London, New York: Informa Healthcare; 2010. 8. Wollina U, Barta U, Uhlemann C, Oelzner P . Lupus erythematosus‑associated red lunula. J Am Acad Dermatol 1999;41:419‑21.

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Figure 3: Histopathological findings: (a) Haematoxylin- stained tissue samples with dilated vessels. (b) Elastica- stain demonstrates elastic fjbres in thickened vessel walls corresponding to arterial vessels (a and b - ×10)

b a

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