Photo Quiz

Enlarging, Painful Nodule Under the Toenail

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Am Fam Physician. 2014 May 15;89(10):793-794.

A 19-year-old woman presented with a slowly enlarging, painful nodule under her left great toenail that appeared two years earlier. She had attempted to remove part of the nodule on her own, but it grew back. She did not have a history of trauma to the area, but she noted increased pain when she wore tight or high-heeled shoes. The patient was a track athlete, and the pain of the nodule caused her to miss a season of competition.

The physical examination revealed a tender 5-mm × 5-mm nodule under the medial side of the distal nail plate (Figure 1). The nodule was firm and displaced the nail plate upward. There was distal onycholysis, but no destruction of the overlying nail plate. No other toes were affected.

Figure 1.


Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Acral-lentiginous melanoma.

B. Glomus tumor.

C. Pyogenic granuloma.

D. Subungual exostosis.

E. Verruca vulgaris (common wart).


The answer

Author disclosure: No relevant financial affiliations.

Address correspondence to Matt Perez, MD, at Reprints are not available from the authors.


1. Turan H, Uslu M, Erdem H. A case of subungual exostosis. Indian J Dermatol Venereol Leprol. 2012;78(2):186.

2. De Berker DA, Langtry J. Treatment of subungual exostoses by elective day case surgery. Br J Dermatol. 1999;140(5):915–918.

3. Wolff K, Johnson RS, Suurmond D, Fitzpatrick TB, eds. Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. 5th ed. New York, NY: McGraw-Hill; 2005.

4. Usatine R, et al., eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009.

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