From the Guidelines
For nail removal, I recommend a stepwise approach beginning with proper patient preparation, including obtaining informed consent and administering a digital nerve block using 1% lidocaine without epinephrine, as outlined in various studies 1. The procedure itself should involve cleaning the area with povidone-iodine or chlorhexidine solution.
- For partial nail removal, use a nail splitter to separate the affected portion, then grasp it firmly with hemostats and remove with gentle traction.
- For complete nail removal, insert a straight hemostat under the nail to separate it from the nail bed before removal. After extraction, apply direct pressure to control bleeding, then dress the wound with antibiotic ointment (such as bacitracin or mupirocin) and a non-adherent dressing.
- Prescribe appropriate pain management with acetaminophen or NSAIDs, and consider a short course of oral antibiotics if infection is present (such as cephalexin 500mg four times daily for 7 days) 1. Instruct patients to keep the area clean and dry, change dressings daily, and elevate the extremity for 24-48 hours to minimize swelling.
- Follow-up should occur within 1-2 weeks to assess healing, as suggested by recent clinical practice guidelines 1. This approach effectively addresses both the immediate removal needs and subsequent wound care to promote proper healing and prevent complications, prioritizing morbidity, mortality, and quality of life as the outcome.
From the Research
Treatment Plan for Nail Removal
- The decision to remove a nail depends on the underlying condition, and the treatment plan should be tailored to the specific diagnosis 2, 3.
- For inflammatory or infectious diseases, treatment may include topical and/or systemic medications, discontinuation of offending drugs, or surgical intervention 3.
- In cases where nail removal is necessary, the use of checklists in preoperative planning can help avoid complications such as iatrogenic fractures 4.
- Nail surgery requires an understanding of specific disease processes, the anatomy of the nail unit, and fluency with key techniques, including surgical approaches to inflammatory nail diseases and nail melanoma in situ 5.
- The need for nail plate removal should be carefully considered, as nonoperative management may be a viable alternative in some cases, with no significant difference in the rate of nail deformities compared to nail bed repair 6.
Key Considerations
- A detailed history and clinical examination of all 20 nail units is essential for diagnosis 3.
- Dermoscopy, diagnostic imaging, and histopathologic and mycological analyses may be necessary for diagnosis 3.
- Patient education on proper nail care and techniques to minimize further damage to the affected nails is important 3.
- The treatment plan should be individualized to the patient's specific condition and needs 2, 3.