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1 Nail Disorders oftheLower Extremity
Dermatoscopy can aid in recognition with diagnosis conrmed histopathologically. First line treatment is injection of
triamcinolone acetonide [30]. Additional therapies include
intramuscular steroids and oral retinoids.
Intralesional and intramuscular corticosteroids are rst
line therapy. Additional therapeutic options include tacrolimus, pimecrolimus, cyclosporine, and retinoids (Fig.1.20)
[30].
Fig. 1.19 Nail psoriasis showing nail dystrophy and periungual
erythema
1.7 Infections oftheNail Unit
1.7.1 Herpes Simplex (Herpetic Whitlow)
Herpetic whitlow is a blistering infection of a digit caused by
the herpes simplex virus [31]. It most commonly occurs in children and has been reported in ungloved health care workers and
contact sport athletes. The condition manifests as painful vesicles swelling, and erythema of the distal phalangeal area. This
may be preceded by burning, pruritis, and/or tingling in the
affected nger. Vesicles may coalesce and lead to a supercial
ulceration. The diagnosis is usually made clinically and can be
conrmed by culture, PCR testing, or Tzanck smear [32].
Herpetic whitlow usually involves a nger, but involvement of a toe has been reported [32]. The condition is selflimiting with resolution of symptoms occurring in 7–10days.
Antiviral therapy may shorten the duration of symptoms.
Recurrence may be precipitated by fever, sun exposure, or
stress (Fig.1.21).
1.7.2 Periungual Viral Warts
Viral warts, or verrucae, are caused by human papillomavirus (HPV), a double-stranded DNA virus that infects
the epidermis. When presenting in and/or around the
nail unit, it is referred to as a periungual wart. A periungual wart may be present underneath the nail plate in the
nail bed or on the lateral or proximal nail folds. Lack of
skin lines, hyperkeratosis, and small pinpoint black dots
Fig. 1.20 Nail lichen planus with pterygium formation on great
toenail Fig. 1.21 Herpetic whitlow of the hallux
1.8 Tumors oftheNails
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Fig. 1.22 Periungual verruca on second digit following cauterization
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(thrombosed capillaries) are seen throughout the lesion
(Fig.1.22) [33].
1.7.3 Onychomycosis
Onychomycosis is a dermatophyte or supercial fungal infection of the nail unit. The condition represents about half of toenail pathologies [34]. Onychomycosis or tinea unguium is
caused by invasion of the nail unit by dermatophytes, nondermatophyte molds, and/or Candida albicans. Infected nails
are described as onycholytic, discolored, and hyperkeratotic
with subungual debris. Clinicians may encounter concomitant
tinea pedis or tinea cruris in patients with onychomycosis.
Onychomycosis is more common in toenails. Fingernail onychomycosis is much less frequent than toenail onychomycosis.
Several subtypes of onychomycosis have been described:
1. Distal (or distal lateral) subungual onychomycosis: This
is the most common type in adults and children. It presents as onycholysis with discoloration, subungual debris,
and hyperkeratosis. Concurrent tinea pedis is often seen
interdigitally or plantarly on the foot. Trichophyton
rubrum is the most common pathogen.
2. Proximal subungual onychomycosis: This most commonly presents in immunocompromised patients as a
leukonychia or white discoloration of the proximal nail
plate. Distal subungual debris is lacking. Trichophyton
rubrum and non-dermatophyte molds are the common
pathogens.
Fig. 1.23 Distal subungual onychomycosis of bilateral great toenails
3. Candidal onychomycosis: Onychomycosis caused by
Candida occurs most frequently in patients with chronic
mucocutaneous candidiasis. The nail can present with
onycholysis and paronychia.
4. Supercial white onychomycosis: The white powdery
material that accompanies this type of onychomycosis
is present on the dorsal aspect of the nail plate. The
condition occurs in tropical climates and it is typically
caused by Trichophyton mentagrophytes or non-dermatophyte molds. Clinicians may mistakenly identify
proximal subungual onychomycosis as supercial
white onychomycosis in very young children due to
their thin nail plates.
Oral or topical antifungal medications are used to treat
onychomycosis. Consideration should be given to environmental factors such as socks, shoe gear, and living quarters
(Fig.1.23).
1.8 Tumors oftheNails
1.8.1 Pyogenic Granuloma
Pyogenic granuloma is a benign vascular tumor commonly
found within the lateral nail sulcus of the nail bed of the
great toe and ngers. Lesions typically present as a pain-
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Fig. 1.24 Pyogenic granulomas are friable skin lesions that frequently
bleed
1 Nail Disorders oftheLower Extremity
Fig. 1.26 Myxoid cyst creating pressure on nail matrix of second nail
and leaving a depression
subtypes include dermatobromas, acquired periungual brokeratomas, and Koenen tumors [36–38]. Dermatobromas are
pea-shaped growths that may develop spontaneously or after
trauma. Acquired periungual brokeratomas are small, asymptomatic eshy growths with a keratotic distal tip that usually
arise following local trauma. Koenen tumors (periungual
bromas) arise in 50% of patients with tuberous sclerosis during childhood or adolescence and occur more commonly on
the toenails. Koenen tumors may present as multiple digitated
growths that can produce a longitudinal groove in the nail
plate due to matrix compression (Fig.1.25).
Fig. 1.25 Periungual broma on top of hallux nail plate
less erythematous mass [35]. The name is a misnomer as
lesions are not associated with purulence or granulomatous changes. Lesions may be induced by trauma and less
frequently by hormonal changes associated with pregnancy or medications including oral retinoids. Surgical
excision, curettage with cautery, and ablative lasers are
therapeutic options (Fig.1.24).
1.8.2 Fibroma/Fibrokeratoma
These are benign tumors of connective tissue that can originate in the nail matrix or within the nail bed and folds. True
bromas develop as painless slow growing benign nodular
tumors that are rm or elastic in consistency. Nail broma
1.8.3 Myxoid Cyst (Mucoid Cyst)
A mucoid cyst is a benign growth in which the synovium
herniates through the joint capsule. The lesion presents as a
solitary, non-moveable, smooth-surfaced papule, or nodule
localized to the lateral or dorsal aspects of the distal interphalangeal joint. Viscous, jelly-like uid ows when punctured. It commonly involves the middle or index ngers of
the dominant hand and can affect the toes. A traumatic event
may trigger it, and the condition is often found in association
with osteoarthritis of the underlying joint. Histologically
they appear like ganglia with a stalk leading from the joint
capsule but they lack a true epithelial lining, making them a
pseudocyst. The cyst is xed to the skin, grows slowly, and
contains a viscous yellowish uid. Some cysts resolve spontaneously [39]. Treatment options include surgery, needling
and drainage, sclerosant or steroid injection, and cryotherapy. Recurrence rates are variable (Fig.1.26) [40].
1.8 Tumors oftheNails
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Fig. 1.28 Nail matrix nevi in a child as viewed with a dermatoscope
Fig. 1.27 Exostosis of distal phalanx after hallux toenail removed
in OR
1.8.4 Subungual Exostosis
Subungual exostosis is an uncommon benign osseocartilaginous tumor affecting the distal phalanx of the ngers and
toes that most commonly affects the hallux. It is characterized by a cartilaginous cap composed of brocartilage and
bone [41]. Lesions most commonly affect persons under the
age of 18 with an equal male-to-female ratio and are associated with a history of pain, erythema, and deformity of the
nail bed progressing over several months [42]. Diagnosis is
made by radiographically. Precipitating factors include
infection, trauma, tumor, hereditary abnormality, and activation of a cartilaginous cyst. Marginal surgical excision with
minimal trauma to the nail bed is the treatment of choice
(Fig.1.27) [43].
1.8.5 Nail Matrix Nevi
Nail matrix nevi presents as a pigmented longitudinal streak
within the nail plate. Nail matrix nevi, a benign manifestation of longitudinal melanonychia, occurs more commonly
in dark-skinned individuals and can occur in individuals of
all ages, with no sex predilection [44]. Dermoscopy may aid
in recognition although a punch biopsy is required to denitively differentiate between benign nail matrix nevus from
subungual melanoma. Pigmentation occurs when melanin is
deposited in the nail matrix by melanocytes. As the nail continues to grow and melanocytes continue to deposit melanin,
a longitudinal streak occurs in the nail plate [15]. Melanin
deposition in a benign nevus occurs by melanocytic hyperplasia, which is an increase in the number of melanocytes
within the nail matrix itself, rather than an increase in amount
of melanin produced by the melanocytes. True nevi are not
typically caused by trauma, fungal infection, or systemic disease. Nail matrix nevi are considered benign, and no further
treatment is necessary once a denitive diagnosis is made
(Fig.1.28).
1.8.6 Bowen’s Disease andSquamous Cell
Carcinoma
Subungual squamous cell carcinoma (SCC) is a malignancy
that can occur in any digit but is more common in ngers
than in toes. Subungual SCC is a rare entity but is the most
common malignancy of the nail bed. The neoplasm can arise
from the nail matrix, the nail bed, the nail groove, or the lateral nail folds. The great toe is most frequently affected.
Growth of the neoplasm is usually slow, and clinical presentation is not usually specic. Appearance can present as paronychia, onycholysis, hematoma, ulceration, or a nodule.
Age of appearance can vary greatly, but subungual SCC most
frequently appears in middle-aged Caucasian males [45].
Bowen’s disease is a very early form of SCC and is commonly referred to as SCC in situ. Biopsy is the gold standard
for diagnosis of subungual SCC. Treatment involves excision of the lesion (Fig.1.29).
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Fig. 1.29 SCC of great toenail bed
1.8.7 Subungual Melanoma
1 Nail Disorders oftheLower Extremity
Subungual melanoma is a neoplasm derived from malignant
melanocytes that originate in the nail matrix. Classic presentation is a dark pigmented band grown longitudinally
through the nail unit and usually occurs on the great toe,
thumb, or index nger. Subungual melanoma is proportionately the most common form of melanoma in dark-skinned
individuals [46]. It initially presents as a longitudinal brown
or black band through the nail unit. It is often misdiagnosed
as a benign nail matrix nevus. As the melanoma evolves
over weeks to months, the neoplasm can undergo changes
such as larger width, irregular pigmentation, extension to
the nail fold (Hutchinson’s sign), ulceration, formation of a
nodule, and resultant nail destruction and dystrophy. In
some cases, subungual melanoma is amelanotic and not pigmented [47]. Subungual melanoma is not thought to be
inuenced by UVA or UVB exposure. Exact pathogenesis is
unknown, but it can be associated with nail bed trauma,
weakened immune system, and familial history of melanoma or other malignancies [48]. Treatment includes
removal of affected nail and wide excision of the nail unit
with adequate margins. Amputation may be necessary.
Prognosis can be good but depends on depth and extent of
invasion (Fig.1.30).
Fig. 1.30 Subungual melanoma of hallux that was misdiagnosed as a
paronychia and pyogenic granuloma
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Superficial Fungal Infections
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oftheLower Extremity
Supercial fungal infections of the lower extremity may be
caused by dermatophytes, yeast, and molds and may become
secondarily infected with bacteria. Dermatophytes that prefer skin, hair, and nails are Trichophyton sp, Microsporum
sp, and Epidermophyton sp. The most common pedal patho-
gen is Trichophyton rubrum. Dermatophytes are contagious
and may be transferred from soil, animals, fomites, and from
other humans.
Wearing shoes, sneakers, and boots contributes to a warm
and moist environment, an optimal milieu for fungi to thrive.
These pedal infections, known as tinea pedis or athlete’s
foot, generally occur in the interdigital areas where prolonged moisture causes maceration, and on the plantar surface of the foot leading to dry, scaly, and itchy skin.
Populations at risk include those who use communal facilities (pools, dorm showers, gyms); those who wear rubber or
non-breathable shoes at work; and persons who are obese,
diabetic, immunocompromised, vascularly compromised
and are unable to perform regular foot hygiene [1].
KOH examination is useful to determine if a dry, scaly
plantar rash is tinea pedis or xerosis. Tinea pedis is positive
for the presence of fungal hyphae (Figs.2.1 and 2.2).
Tinea pedis can serve as a nidus of infection resulting in
spread to other body sites. Common types of dermatophytosis
are tinea corporis (body), tinea cruris (groin), tinea manuum
(hands), tinea capitis (scalp), and onychomycosis (nails).
Tinea pedis can resemble other conditions including
eczema, plaque and pustular psoriasis, allergic contact dermatitis, irritant contact dermatitis, dyshidrosis, xerosis, secondary syphilis, erythrasma, pitted keratolysis, and soft corn
(heloma molle).
2
Fig. 2.1 Plantar xerosis has scale within the skin lines and is KOH
negative
2.1 Interdigital Tinea Pedis
Interdigital tinea pedis is the most common form and is
often located within the fourth interspace (between the
fourth and fth toes) although all interspaces can be
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
T. C. Vlahovic, S. M. Schleicher, Atlas of Lower Extremity Skin Disease, https://doi.org/10.1007/978-3-031-07950-4_2
Fig. 2.2 Severe plantar xerosis
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affected with spread plantarly to the toe sulcus. The condition can present as a dry, pruritic, and scaly rash or as
inamed, macerated tissue deep in the interspace which can
ssure, ulcerate, and become secondarily infected with
bacteria such as Corynebacterium or Pseudomonas, resulting in localized cellulitis or lymphangitis (Figs. 2.3, 2.4,
and 2.5).
2 Supercial Fungal Infections oftheLower Extremity
Fig. 2.3 Dry interdigital tinea pedis
Fig. 2.4 Macerated tissue in interdigital tinea pedis
Fig. 2.6 Moccasin tinea pedis
2.2 Moccasin Tinea Pedis
T. rubrum is the most common cause of this chronic form of
tinea pedis that affects the plantar and lateral aspects of the
foot in a moccasin shoe-type distribution [1]. Usually bilateral, it presents as serpiginous circular scale which may be
erythematous and pruritic. Associated ndings can include
ssures and onychomycosis (Fig.2.6).
2.3 Vesicular or Vesiculobullous Tinea
Pedis
This condition presents as vesicles on a background of erythema localized to the dorsum of the foot and is possibly
secondary to an autosensitization dermatitis triggered by
dermatophytes. Lesions may be painful or pruritic.
Differential diagnosis includes pustular psoriasis and bacterial infection (Fig.2.7) [1].
Fig. 2.5 Superinfected tinea pedis with inammation dorsally
2.4 Tinea Incognito
Tinea incognito results from a dermatophyte infection that
has been inappropriately treated with topical steroids [2].
The condition may have initially been diagnosed as eczema
2.6 Tinea Nigra
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Fig. 2.7 Vesicular tinea pedis
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Fig. 2.8 Tinea incognito resulting from Class I topical steroid use on a
tinea pedis infection
or psoriasis. Pruritus, scaling, and erythema improve at onset
but over time the infection extends. A nondescript macular
rash evolves into a circinate patch with raised borders and at
times scattered vesicles. KOH (potassium hydroxide) preparation reveals numerous fungal elements. Treatment entails
discontinuation of topical steroids and institution of antifungal therapy (Fig.2.8).
2.5 Majocchi’s Granuloma
Majocchi’s granuloma, also referred to as granuloma trichophyticum, is a suppurative and granulomatous folliculitis
caused by a fungal infection. In most cases the causal agent
is Trichophyton rubrum [3]. The condition often occurs in
association with tinea unguium and tinea pedis. In women,
Majocchi’s granuloma may be precipitated by shaving and
Fig. 2.9 Majocchi’s granuloma on the leg
waxing. Cases have been related to both topical steroid use
and immunosuppression. When associated with the latter
common ndings include indurated plaques with erythematous subcutaneous nodules [4].
Conrmation of Majocchi’s granuloma is best achieved
by fungal culture and/or biopsy. Because the infection is
deep-seated within hair follicles topical antifungals are ineffectual. Therapeutic options include terbinane and itraconazole (Fig.2.9) [4].
2.6 Tinea Nigra
Tinea nigra is a supercial fungal infection caused by
Hortaea werneckii. Predominantly found in tropical and subtropical locales, it can be seen in persons returning from
endemic areas [5]. The disorder presents as a well-dened,
asymptomatic, brown-black hyperpigmented macule or
patch without scale on the hands and feet and may be misdiagnosed as an acral nevus or melanoma. KOH and fungal
culture are positive and the condition responds well to topical antifungals (Fig.2.10).
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Fig. 2.10 Tinea nigra on the nail unit that was misdiagnosed as acral
melanoma
2 Supercial Fungal Infections oftheLower Extremity
areas. Patients can also use ultraviolet shoe sanitizers to
decrease the bioburden in daily shoe gear.
Often the patient will self-treat with over-the-counter
preparations that consist of medicated foot powders, sprays,
and creams such as Castellani’s paint, gentian violet, undecylenic acid, miconazole, clotrimazole, tolnaftate, butenane,
and terbinane. Prescription antifungal topical preparations
include the following:
• Ciclopirox
• Econazole
• Ketoconazole
• Luliconazole
• Naftine
• Oxiconazole
• Sertaconazole
Longstanding or severe infections may warrant an oral
antifungal. Approved medications are griseofulvin, terbinane, itraconazole, and uconazole. In addition to a topical
antifungal, the clinician may add a keratolytic to descale the
plantar skin and decrease transepidermal water loss. Lactic
acid, salicylic acid, and urea preparations may facilitate efcacy of the antifungal.
Bacterial superinfection may require topical and/or oral
antibiotics for adequate control. Topical preparations that
decrease sweating such as aluminum chloride solution and
powders, as well as botulinum toxin injection, may help prevent recurrence.
2.7 Laboratory Tests
A supercial fungal infection is often suspected based on
history and examination. Various laboratory tests may be
used to conrm the diagnosis such as KOH examination,
fungal culture, periodic acid Schiff (PAS) stain, and polymerase chain reaction (PCR). A punch biopsy may be useful
to differentiate tinea from an inammatory skin disorder like
psoriasis.
When sampling a dermatitis for KOH or culture, scraping
of the leading edge with a No. 15 blade provides the highest
yield. Cultures should be observed for up to 4weeks due to
the slow growth of dermatophytes.
2.8 Treatment
Patients should be educated on foot hygiene: drying between
toes, changing socks and shoes daily, disinfecting family
showering areas, and wearing shower shoes in communal
References
1. Nigam PK, Saleh D. Tinea Pedis. [2021 Jun 7]. In: StatPearls
[Internet]. Treasure Island, FL: StatPearls Publishing; 2022.
2. Nowowiejska J, Baran A, Flisiak I.Tinea incognito: a great physician pitfall. J Fungi (Basel). 2022;8(3):312. https://doi.org/10.3390/
jof8030312.
3. Boral H, Durdu M, Ilkit M.Majocchi’s granuloma: current perspectives. Infect Drug Resist. 2018;11:751–60. https://doi.org/10.2147/
IDR.S145027.
4. Castellanos J, Guillén-Flórez A, Valencia-Herrera A, etal. Unusual
inammatory tinea infections: Majocchi’s granuloma and deep/systemic dermatophytosis. J Fungi (Basel). 2021;7(11):929. https://doi.
org/10.3390/jof7110929.
5. Eksomtramage T, Aiempanakit K. Tinea nigra mimicking
acral melanocytic nevi. IDCases. 2019;18:e00654. https://doi.
org/10.1016/j.idcr.2019.e00654.
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