Warts of the nail unit: surgical and nonsurgical approaches

Background: Warts are the most common nail tumor and mostly affect children and young adults. Periungual warts are usually due to HPV-1, 2, and 4. Development of periungual warts is favored by maceration and trauma, especially nail biting. Objective: To discuss the biology, clinical features, and medical and surgical treatment of periungual warts. Methods: Review of the literature and personal experience. Results: The natural course of warts makes aggressive approaches restricted to selected cases. Medical treatments, usually topical, include keratolytic agents, virucidal agents, and immunomodulators. All choices have been utilized successfully, but keratolytic agents are the best first-line approach. Surgical treatments include cryotherapy, surgical excision, electrosurgery, infrared coagulation, localized heating with a radio-frequency heat generator and laser therapy, especially the Er:YAG laser, which has an excellent safety profile. Conclusions: Definitive cure is not guaranteed by any therapy and periungual warts can recur and become larger after correct treatment.