From the Guidelines
Nail avulsion is a surgical procedure that involves the removal of part or all of a nail, and it is typically performed to treat conditions like ingrown toenails, fungal infections, or nail trauma, with the most recent and highest quality study suggesting that surgical intervention, including partial nail avulsion, may be considered for the treatment of paronychia, especially in cases where there is significant pain, discharge, or nail plate separation 1. The procedure begins with local anesthesia to numb the affected digit, and for partial avulsion, only the problematic portion of the nail is removed, while total avulsion involves removing the entire nail.
- The decision to perform a partial or total avulsion depends on the extent of the condition being treated, with partial avulsion being suitable for conditions like ingrown toenails where only a portion of the nail is affected.
- After removal, phenol (88%) may be applied to the nail matrix for 1-3 minutes to prevent regrowth (phenolization), particularly for recurrent ingrown toenails. Some key points to consider in the management of nail avulsion include:
- Post-procedure care, which includes daily soaking in warm water with antibacterial soap for 5-7 days, applying antibiotic ointment (such as bacitracin or mupirocin), and covering with a sterile bandage.
- Oral antibiotics like cephalexin 500mg four times daily for 7 days may be prescribed if infection is present.
- Pain management typically involves acetaminophen or NSAIDs, and patients should elevate the affected extremity for 24-48 hours and limit physical activity for about a week. The nail bed typically heals within 2-3 weeks, though complete nail regrowth takes 3-12 months if the matrix wasn't destroyed, and this procedure is effective because it directly addresses the source of pain and infection by removing the problematic nail tissue, allowing proper healing and, when combined with phenolization, reducing recurrence rates to less than 10% compared to nearly 70% without chemical matricectomy, as supported by the most recent guidelines on the prevention and management of dermatological toxicities related to anticancer agents 1.
From the Research
Treatment for Nail Avulsion
The treatment for nail avulsion, which is the surgical removal of a nail, can be performed using different methods and techniques.
- Surgical nail avulsion is a frequently undertaken procedure that may be performed for diagnostic or therapeutic purposes, such as exploration of the nail bed, nail matrix, and nail folds, or for conditions like onychocryptosis, warts, onychomycosis, and chronic paronychia 2.
- The procedure is typically carried out under local anesthesia with or without epinephrine, and the choice of technique may depend on the specific indication and the patient's condition 2, 3.
- Partial nail avulsion with phenolization has been shown to be an effective treatment for ingrowing toenails, with better results than partial avulsion with matrix excision 3.
- Basic nail plate avulsion can be performed in a physician's office, and certain preoperative, operative, and postoperative procedures can help assure a successful outcome 4.
- A new surgical modification of nail avulsion using an 11-blade surgical blade instead of nail clippers has been proposed, which may result in less trauma to the nail bed and better post-procedure outcomes 5.
- Nonsurgical avulsion of nail dystrophies can also be achieved using urea ointment, which is a nonsurgical and atraumatic method 6.
Surgical Techniques
Surgical techniques for nail avulsion may include:
- Distal approach 2
- Partial nail avulsion with phenolization 3
- Matrix excision 3
- Use of an 11-blade surgical blade 5
- Nonsurgical avulsion using urea ointment 6