Squamous Cell Carcinoma in Situ of the Nail Unit: Current Evidence and Recommendations for Patient Centered Treatment

Squamous cell carcinoma in situ of the hand and nail is an infrequent tumor but represents the majority of hand and nail malignancies. While the conventional treatments of invasive nail unit squamous cell carcinoma include Mohs micrographic surgery, wide local excision, or distal digit amputation, no standardized management paradigm for in situ disease exists and the necessity of surgical options is debated. This review aims to discuss the most commonly reported treatment methods and critically assess relevant management considerations in order to facilitate appropriate treatment decisions for nail unit SCCis across dermatologic practice settings. Assessment of the current literature reveals insufficient evidence to determine a standardized treatment for nail unit squamous cell carcinoma in situ. Rather, management is greatly impacted by multiple factors including the presence of subungual involvement, surgical candidacy, importance of curative treatment, and patient preferences regarding cosmesis and function versus cure. When cure is desired, Mohs micrographic surgery is the treatment of choice in most cases. In the setting of desired curative intent, but poor surgical candidacy, radiotherapy may be effective and provide a reasonable chance of functional and cosmetic preservation. Other methods including photodynamic therapy, electrodesiccation and curettage, cryotherapy, and intralesional chemotherapeutics may be appropriate in specific circumstances, but are generally limited by lack of evidence or impracticalities. Lastly, observation with palliation may be appropriate when considering exceedingly rare disease-related mortality.