Squamous cell carcinoma of the nail unit with evidence of bony involvement: a multidisciplinary approach to resection and reconstruction.

BACKGROUND

Squamous cell carcinoma (SCC) of the nail bed is a rare disorder that is often misdiagnosed for years before definitive diagnosis with biopsy. Proper evaluation of this carcinoma includes radiographic evaluation for bony involvement of the phalanges of the affected digit. If bony involvement is evident by x-ray, amputation of the distal phalanx or the affected digit is warranted. Mohs micrographic surgery of the affected nail unit is advantageous in preserving vital tissue for reconstruction after phalangeal amputation by a hand surgeon, thus maximizing preservation of the densely innervated tissue from the volar finger pulp. This approach may maximize functional capacity of the reconstructed digit.

OBJECTIVE

To describe a multidisciplinary approach to resection, amputation, and reconstruction of digits with SCC of the nail bed.

METHODS

This is a description of three cases and a review of the pertinent medical literature.

RESULTS

Three SCCs of the nail bed were excised with Mohs micrographic surgery, preserving the volar pulp and skin of the distal finger. The patients were then referred for distal phalanx amputation and reconstruction by a hand surgeon. All patients remained disease free with acceptable function of the reconstructed digits at 15, 17, and 38 months of follow-up.

CONCLUSION

Although uncommon, SCC of the nail bed must be considered in all nails with chronic disease. Preoperative evaluation should include hand radiographs in search of bony involvement. Tissue-sparing excision combined with distal amputation of the affected phalanx and reconstruction of the digit using spared tissue may maximize hand and digit function.