Treatment of Multiple Periungual Pyogenic Granulomata from Pincer Nails with Pulsed Dye Laser

Abstract

The authors have indicated no significant interest with commercial supporters.M ultiple periungual pyogenic granulomata are an uncommon phenomenon. We present a case of a 16-year-old boy with multiple pyogenic granulomata of the nail folds caused by pincer nails. These lesions were successfully treated with two sessions of pulsed dye laser (PDL; 595 nm, 7-mm spot size, 8 J/cm 2 , 0.45-ms pulse width) with a 1-week interval after failure of surgical excision, and their recurrence has been prevented with appropriate home nail care. Along with this interesting case, a brief review of the reported causes of multiple periungual pyogenic granulomata and the treatment of pyogenic granulomata with PDL will be discussed. CaseA 16-year-old boy presented to clinic with a 6-month history of a friable papule on the lateral periungual region of the left third finger. He was first seen at an outside clinic where the lesion was thought to be an abscess and treated with incision and drainage. He had also been treated with amoxicillin/clavulanic acid, ciprofloxacin, and topical mupirocin. The lesion did not heal, remaining painful, friable, and occasionally purulent. He underwent a biopsy, which was consistent with pyogenic granuloma, followed by surgical resection, with subsequent complete recurrence.On examination at our clinic, pincer nails were noted, as well as an eroded, crusted papule of the lateral nail fold of the left third finger (Figure 1). The patient was started on imiquimod 5% cream once daily. After 3 weeks of treatment, his finger appeared more edematous and erythematous, and he had begun to develop a similar lesion on the fourth finger, which he was also treating with imiquimod. At that time, because of concern for superinfection, imiquimod was discontinued, and the patient was started on a 7-day course of levofloxacin along with topical econazole and triple antibiotic ointment. Fungal and bacterial cultures were negative. Another biopsy was performed showing vascular proliferation with a dense lymphoid infiltrate. At this time, we debrided the serosanguineous crust from the lesions, along with the offending portion of the nail plates (Figure 2), and treated the lesions with pulsed dye laser (PDL; 595 nm, 7-mm spot size, 8 J/cm 2 , 0.45-ms pulse width) in two sessions 1 week apart. These aggressive laser settings were chosen to maximize the therapeutic response by delivering the greatest amount of energy in the least amount of time. Prior experience in treating these lesions with longer pulse widths, specifically, had not proven to be successful. Pulses were stacked two to three times, with purpura being the point at which a therapeutically meaningful dose of energy was thought to be delivered ( Figure 3A). The patient was then counseled to cut his nails straight across and allow them to grow out slightly and he was shown how to tape the nail fold back to alleviate pressure. He was also

Pyogenic Granuloma: Treatment with the 1,064-nm Long-Pulsed Neodymium-Doped Yttrium Aluminum Garnet Laser in 20 Patients

“…Flat PyG can be treated successfully using the pulsed dye laser (PDL) . Treatment using the dye laser is gentle, especially at anatomically difficult sites, such as periungually . Thanks to its wavelength (585–595 nm) and the subsequent limited penetration depth, the PDL is a therapeutic option with few side effects, although its use is restricted to flat, small PyG, which means it is not suitable for most of the PyGs in our study.…”

Pincer Nail Deformity: Clinical Characteristics, Causes, and Managements

“…This results in reduced healing time and desired cosmetic effects. Subsequently, Miller and Levitt reported successful outcomes after using a pulsed dye laser to treat PND with multiple periungual pyogenic granulomas [43]. (Figure 8) [44].…”