Periungual warts are warts that form around the fingernails or toenails and are among the most difficult wart types to treat effectively. Their location next to the nail plate and nail-forming structures limits treatment options, increases the risk of recurrence, and raises the possibility of nail damage if not managed carefully. This article explains why periungual warts behave differently, what makes treatment more complex, how clinicians assess them, and why specialist-led care in London is often advised.
Nail Anatomy
The area around the nail is structurally different from most other skin surfaces. The nail unit includes the nail plate, nail folds, nail bed, and nail matrix, all of which work together to produce and support nail growth.
Periungual warts develop within or adjacent to these structures. Unlike warts on flatter skin, there is very little spare tissue around the nail, meaning treatment margins are narrow. The nail matrix, in particular, is sensitive to injury. Damage to this area can lead to long-term changes in nail shape, thickness, or growth direction.
Another challenge is that periungual warts may extend beneath the nail edge or into the nail fold. This means the visible portion of the wart does not always reflect its true size or depth, making superficial treatment less reliable.
Treatment Limits
Many commonly used wart treatments must be adapted or avoided around the nails due to safety concerns.
| Treatment approach | Limitation near the nail |
|---|---|
| Salicylic acid and other topicals | Can damage surrounding skin and nail folds |
| Cryotherapy | Risk of freezing the nail matrix if not precisely targeted |
| Repeated freezing | Increases inflammation and nail distortion |
| Aggressive excision | Higher risk of scarring or altered nail growth |
Because of these limitations, periungual warts often require more conservative or staged treatment. Attempting overly aggressive clearance in one session may increase the risk of complications without improving long-term outcomes.
Hidden Spread
One reason periungual warts are difficult to eradicate is their tendency to spread in subtle ways. Human papillomavirus (HPV), which causes warts, can infiltrate tiny breaks in the skin around the nail. This is particularly common in people who bite their nails, pick at cuticles, or regularly trim nail folds.
In some cases, wart tissue spreads under the nail plate, where it is shielded from topical treatments and harder to access with freezing. This hidden extension explains why periungual warts may persist despite multiple treatment attempts and why recurrence is common.
Recurrence Risk
Periungual warts are known for returning after treatment. This does not necessarily indicate that treatment was poorly performed. Several factors increase recurrence risk in this area:
- Residual microscopic wart tissue after treatment
- Repeated trauma from nail biting, manicures, or occupational hand use
- Slower immune clearance in adults
- Difficulty treating under-nail involvement fully
Recurrence may occur weeks or months after apparent clearance. Understanding this risk helps patients make informed decisions about treatment and follow-up.
Assessment First
Because of the complexity of periungual warts, assessment is a critical first step. During consultation, clinicians typically focus on:
- Confirming the diagnosis, as other nail-area lesions can mimic warts
- Identifying whether the wart involves the nail matrix or extends under the nail
- Reviewing previous treatments and response
- Assessing nail health and growth pattern
This assessment determines whether treatment is appropriate and which method is safest. In some cases, short-term monitoring or delayed treatment may be recommended if inflammation is present.
Treatment Planning
Treatment planning for periungual warts prioritises precision and preservation of nail function. The aim is to reduce viral tissue while protecting the nail matrix and surrounding skin.
Depending on individual findings, treatment may involve:
- Carefully targeted cryotherapy
- Limited surgical removal in selected cases
- Staged treatment rather than a single aggressive session
Same-day treatment may be possible in some cases, but this depends on the size, position, and behaviour of the wart. Not all periungual warts are suitable for immediate removal.
Nail Outcomes
Concerns about nail appearance and growth are common with periungual warts. Any treatment in this area carries a risk of temporary or permanent nail changes.
Possible outcomes include:
- Temporary nail ridging or surface irregularity
- Short-term inflammation around the nail fold
- Rarely, persistent nail growth changes if the matrix is affected
These risks are discussed during consultation so patients can weigh treatment benefits against potential effects on nail appearance.
Specialist Care in London
At London Wart Clinic, and City Dermatology Clinic London, periungual warts are managed with particular caution due to their anatomical complexity. Assessment and treatment are carried out by clinicians experienced in minor skin surgery and reconstructive techniques, where protecting function and appearance is essential.
This includes surgeons such as Dr Nicki Bystrzonowski, Dr Giulia Luciano, Mr Georgios Pafitanis, and Mr Parviz Sadigh, who regularly manage warts in sensitive or high-risk areas.
Treatment decisions are individualised, and suitability is always determined following assessment.