Painful nails: A practical approach to the diagnosis and management of painful nail conditions

Abstract

Because several nail disorders share similar clinical features, their diagnosis and management can be challenging to clinicians. The physical examination may disclose localized abnormalities or point to an underlying systemic disease, requiring additional workup. Furthermore, cosmetic distress and nail-related symptoms (e.g., tingling, stinging, numbness, and pain) are common factors that influence the patient's search for medical assistance. Nail pain (i.e., onychalgia) can accompany both localized and systemic pathology. Onychalgia can be acute or chronic according to the time of evolution; patients may describe it as intermittent or constant, and as a throbbing, burning, sharp, or shooting sensation denoting the nature of the pain. It may be exacerbated by colder temperatures, touch, and increased activity (e.g., manipulating objects, walking). We present four main groups of conditions that might cause nail pain: nail tumors, nail deformities, inflammatory or infectious diseases, and external or traumatic agents. Our article includes an overview of the clinical features, as well as diagnosis and management pearls for each entity. Physicians (dermatologists and nondermatologists) should be aware that abnormalities of the ungual and subungual space are not exclusive of dermatological disorders but may also be present in noncutaneous contexts.

Expanding the Differential Diagnosis of the Painful Nail: A Case of an Onychopapilloma with Neuroma

“…Differential diagnosis of a painful nail includes glomus tumor, leiomyoma, subungual keratoacanthoma, subungual epidermoid inclusion cyst, subungual exostosis, or onychomatricoma [ 8 ]. Glomus tumor is a benign painful neoplasm that may present in the subungual region as a small (<10 mm in diameter), pinkish-red or bluish spot or with LE and distal notching.…”

“…Glomus tumor is a benign painful neoplasm that may present in the subungual region as a small (<10 mm in diameter), pinkish-red or bluish spot or with LE and distal notching. Patients will often complain of moderate to severe pinpoint pain with cold sensitivity, exacerbated with pressure [ 3 , 8 ]. Though very rare, subungual leiomyoma should be considered in the differential diagnosis of LE when accompanied by pain.…”

“…Subungual keratoacanthomas arise in the most distal portion of the nail bed as painful keratotic nodular lesions, causing onycholysis and sometimes bone erosion from rapid enlargement. Nail pain is described as gradual, constant, and sharp [ 8 ]. Epidermal inclusion cysts are common benign skin tumors and can infrequently appear in the nail apparatus following trauma.…”

“…Subungual cysts are slow-growing benign tumors and may cause onychodystrophy, clubbing, onycholysis, and subungual hyperkeratosis. Late-onset nail pain may result from bone compression and is described as constant, shooting, and severe in intensity [ 8 ]. Subungual exostosis is a benign osteocartilaginous tumor that arises from the distal phalanx, usually secondary to trauma or chronic irritation.…”

“…Subungual exostosis is a benign osteocartilaginous tumor that arises from the distal phalanx, usually secondary to trauma or chronic irritation. It presents as a small, well-circumscribed, pink or flesh-colored subungual nodule that may cause elevation or detachment of the nail plate; pain is described as constant, throbbing, and moderate to severe in intensity [ 8 ]. Onychomatricoma is a rare benign nail matrix tumor, most often associated with trauma or onychomycosis and classically presents with xanthonychia, ungual hyperkeratosis, and splinter hemorrhages with longitudinal and transverse overcurvature of the nail plate.…”