Koenen Tumors Predisposing to Recurrent Onychomycosis: An Interesting Case

Koenen tumors are uncommon nail tumors seen characteristically in patients of tuberous sclerosis. They cause longitudinal nail grooves, onycholysis, nail deformity or nail dystrophy which may predispose the affected nails to secondary infections. We report a case of a 35-year-old male with multiple koenen tumours having recurrent onychomycosis. A 35-year-old male presented with whitish discoloration and loss of distal part of nails from 2-3 years and scaling on right hand and feet from 1 year. On examination, there was scaling over dorsal aspect of right hand and both feet. There was subungual hyperkeratosis, distal onycholysis and distal nail dystrophy and nail plate splitting in multiple nails. Digitate growths arising from proximal nail fold (Koenen tumours) were also noted. KOH examination from skin and nails demonstrated fungal hyphae. Patient recounts taking multiple courses of topical and oral antifungals giving temporary relief but recurrence of lesions occurs after stopping treatment. It is possible that Koenen tumours themselves or the nail changes caused by them like nail plate thinning, depression or dystrophy act as portal of entry for fungus and thus, predispose to recalcitrant, chronic or recurrent fungal nail infections. Similar cases of onychomycosis coexisting with other nail tumors have also been reported. There is a need of more studies on association of nail tumors with onychomycosis as a risk factor and management in these cases.