Session type: Focus on
- Thursday, 7 May
- 10:45 - 12:15 EEST
How to recognise a malignant nail tumour
Prof. Bertrand Richert (Brussels, Belgium) offered a practical framework for diagnosing the two principal malignant nail tumours: squamous cell carcinoma (SCC) and melanoma. He emphasised that monodactylic warty lesions or longitudinal melanonychia (LM) in adults over 50 should always raise suspicion and prompt biopsy. Nail melanoma presents as LM in around 70% of cases, while approximately 30% of nail bed melanomas are amelanotic and may mimic benign conditions such as pyogenic granuloma.
Prof. Richert also briefly highlighted benign nail tumours that may resemble malignant disease, reinforcing the broad differential diagnosis of LM. He emphasised that onychoscopy may aid differentiation, but biopsy remains essential, particularly for nodules of the nail bed and atypical pigmented lesions.
“Any nodule of the nail bed should always be biopsied. You could save a patient’s life.”
Nail changes in systemic diseases
Dr. André Lencastre (Lisbon, Portugal) named nine “less specific” nail signs commonly associated with systemic disease: Beau’s lines and onychomadesis, splinter haemorrhages, nail matrix lichen planus-like onychopathies, leukonychia, melanonychia, red lunula, ventral pterygium, periungual capillary changes and clubbing.
Beau’s lines and onychomadesis were described as retrospective markers of systemic insult, while proximal, polydactylous splinter haemorrhages may indicate infective endocarditis, vasculitis, haematological disease or TYK2 inhibitor therapy. Ventral pterygium and capillaroscopic abnormalities were emphasised as important clues to connective tissue disease.
Dr. Lencastre concluded that isolated nail findings may provide an important opportunity for the early diagnosis of systemic disease.
Management of periungual warts
Prof. Dimitrios Rigopoulos (Athens, Greece) reviewed the management of periungual warts, a common but therapeutically challenging HPV-related condition affecting up to 30% of children and 12.9% of adults. Predisposing factors include nail biting, trauma, immunosuppression, dermatitis and occupational water exposure. Diagnosis is primarily clinical, supported by dermoscopy, while biopsy is recommended for longstanding, treatment-resistant or monodactylic lesions in adults over 40–50 years.
Prof. Rigopoulos presented a broad therapeutic landscape spanning destructive, antiproliferative and immunological approaches, with treatment selection guided by patient age, immune status, lesion number and location. Emerging and recalcitrant-case strategies include laser-assisted therapies, local hyperthermia, intralesional immunotherapy and cidofovir ointment.
Handling disappearing nail bed
Dr. Lourdes Navarro Campoamor (Madrid, Spain) reframed disappearing nail bed (DNB) as a commonly misdiagnosed and misunderstood condition driven by mechanical–biological failure of the nail unit rather than fungal disease. She explained that the nail bed is “not autonomous”, but a dependent epithelium maintained through mechanical interaction with the nail plate. Chronic onycholysis disrupts this relationship, leading to keratinisation, shortening, narrowing and progressive loss of nail bed identity.
Dr. Campoamor explained how management focuses on restoring the plate–bed relationship through a seven-step practical algorithm addressing mechanical causes, environmental optimisation, keratinisation control, taping, orthonyxia, mechanical stimulation and surgery for refractory disease.
“No contact means no nail bed, and no nail bed means no functional nail. Treat the mechanism, not the appearance.”
Key takeaways
- Nail disorders can provide important clues to both malignancy and systemic disease, with early biopsy and recognition of atypical nail findings playing a critical role in timely diagnosis.
- Across nail conditions, speakers emphasised moving beyond surface appearance towards more mechanistic, individualised, and function-preserving management approaches.