What is the treatment for subungual exostosis?

Treatment of Subungual Exostosis

Surgical excision is the definitive treatment for subungual exostosis, with complete removal of the bony growth being essential to prevent recurrence. 1

Diagnostic Considerations

• Subungual exostosis is a benign bony growth that typically affects the toes, particularly the hallux (great toe)
• Presents as a painful growth underneath the nail, often causing nail deformity
• Radiographic examination is essential for diagnosis and surgical planning
• Biopsy may be required to differentiate from other conditions such as subungual melanoma 2

Treatment Algorithm

First-Line Treatment: Complete Surgical Excision

1. Surgical Approach:

   • Local excision under local anesthesia as a day case procedure 3
   • Meticulous removal of all tumor tissue from the terminal phalanx
   • Careful attention to preserving the nail matrix when possible

2. Surgical Technique Options:

   • Marginal excision with complete removal of the cartilaginous cap 4
   • For larger lesions, a more extensive approach may be required

3. Post-Excision Management:

   • Wounds may be allowed to heal by secondary intention 3
   • Alternatively, a pedicled vacuum-assisted closure (VAC) device can be used for larger defects to minimize tissue deficit 5

Special Considerations

• Pediatric Cases: Higher recurrence rates observed in younger patients (10% recurrence rate in one study, primarily in patients aged 9-13 years) 3
• Nail Matrix Involvement: Risk of permanent nail dystrophy if the nail matrix is damaged during surgery 3
• Location: Most commonly affects the great toe (71% of cases), but can also occur on other toes (19%) and fingers (10%) 3

Follow-up Care

• Regular follow-up for at least 12-18 months to monitor for recurrence
• Most recurrences occur within the first year after surgery 3
• Evaluate for proper nail regrowth and any signs of recurrent pain or growth

Potential Complications and Management

• Recurrence: Requires repeat surgical excision with more thorough removal
• Nail Dystrophy: May be permanent if nail matrix is damaged during surgery
• Wound Healing Issues: Consider advanced wound care techniques such as VAC therapy for larger defects 5

Key Points for Optimal Outcomes

• Complete excision is critical - partial removal leads to recurrence
• Preoperative antiseptic procedures and adequate postoperative analgesia are important 3
• Careful surgical technique to preserve the nail matrix when possible
• Thorough removal of all tumor tissue, including the cartilaginous cap

With proper surgical technique and complete excision, the prognosis is excellent with low recurrence rates in adult patients and good functional and cosmetic outcomes.