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Periungual pyogenic granuloma‐like lesions following plaster cast immobilization: a case managed with symptomatic therapy

Pyogenic granuloma (PG) is an eruptive capillary hemangioma not uncommonly seen in the nail folds. The most common causes of periungual PG include acute and chronic trauma, infection, drugs, and high levels of sex hormones associated with pregnancy [ 1 ] . Some patients develop more than one lesion. PG-like lesions of the nail folds, accompanied by onychomadesis, have also been reported as a rare complication of plaster cast immobilization and attributed to mild peripheral nerve injury [ 1–4 ] . While neurological symptoms observed in most of the cases previously reported support this hypothesis, we recently treated a patient with multiple PG-like lesions following plaster cast immobilization without any associated neurological fi ndings. A 25-year-old male sustained a closed traumatic fracture of the middle phalanx of the left third fi nger. The hand was placed in a plaster cast that extended from halfway up the arm down to the proximal nail folds of the second to fi fth fi ngers. Two weeks after removal of the plaster cast, initial periungual edema was noted on the second to fourth fi ngers of the same hand (Figure 1 a). Subsequently, the lesions turned into erosive erythematous papules and nodules (Figure 1 b). The patient reported no associated neurological symptoms such as paresthesia, pain, or increased sweating, and the neurological exam, too, was unremarkable. Clinically, the papulonodular lesions were considered to be PG. Initial treatment included wet dressings, topical silver nitrate, and systemic antibiotics (amoxicillin/clavulanic acid for ten days). Due to lack of clinical improvement, the patient was started on oral methylprednisolone (0.3 mg/kg/ day) – tapered over the course of twelve days – leading to a decrease in the size of the tumors (Figure 1 c). The lesions were then treated with a topical corticosteroid/antibiotic preparation (fusidic acid combined with betamethasone valerate), resulting in the regression of edema and nearly complete healing of the PG-like lesions after six weeks (Figure 1 d). All three affected fi ngers showed onychomadesis (Figure 1 e) after the lesions had regressed but this sequela, too, resolved without any nail deformity within six months (Figure 1 f). No recurrence was observed during the one year follow-up period. Although retronychia was also considered in the differential diagnosis, factors that argued against this condition