A Patient presented to the office with a six month history of this lesion on th left hallux.  The mass is firm and painless but disrupts his ability to wear normal shoes.

How would you manage this patient?

I would definitely do further work up to investigate this, including getting a tissue biopsy as well as getting more information from the patient.  I would also beconcerned that the mass is painless. Is the patient sensate?  How has the mass changed over the time. Does it bleed or show signs of infection? Does the patient have a history ingrown toenail?  This could be something benign or something more serious, so better safe than sorry.

Janice P. Clark, DPM
Medical College of Georgia

I agree with Janice.  Biopsy is key.  It looks like a pyogenic granuloma (based on appearance and location in the nail groove) but should be painful, friable, and easily bleeding.  I'm sure all of us would start with an x-ray in the office.  An MRI may be a thought here as well.  It always surprises me when people walk in to the office with things like this.  How did this person not seek out care earlier!  I'd be cautious in regards to the psychology of the patient.  No mentally intact person would leave this for 6 months!

I would just consent for complete excision, then send the entire lesion to pathology. Yes, you would have to avulse the nail at the same time.

If it's benign, you are done. If it's malignant, the patient is looking at toe/foot/leg amp, based on the oncology input.

I may want to do x-ray beforehand to see if there is any bone destruction, but I am doubtful that MRI would change my treatment much. It does look like a benign granuloma to me as well.  

Interesting case... I would be interested in the pathology report, Ryan.

One of my old cases... 

I excised it completely, bled pretty good and I did hemostasis with silver nitrate stick. The pathology report said "benign granuloma." I have no idea how it started. The patient said it grew over 2 months.

I was just amazed it didn't come off on its own, and the fact that the patient didn't pick on it until she came to see me!

Even dermatologists can not tell a granuloma from a melanoma with certainty without a biopsy.  I had a similar case that  the referring dermatologist had told the patient was a granuloma secondry to an ingrown nail.