How do you assess and manage onycholysis?

Assessment and Management of Onycholysis

The management of onycholysis requires prompt identification of the underlying cause, obtaining appropriate cultures when infection is suspected, and implementing targeted interventions based on severity to prevent permanent nail damage and complications.1

Assessment of Onycholysis

Clinical Presentation

• Separation of the nail plate from the nail bed, appearing as a whitish or yellowish discoloration
• May be associated with pain, discomfort, or cosmetic concerns
• Can affect fingernails, toenails, or both

Diagnostic Evaluation

• Thorough visual examination of all affected nails
• Assess for:
  • Extent of separation (partial vs. complete)
  • Presence of discoloration (white, yellow, brown, green)
  • Associated nail changes (thickening, pitting, ridging)
  • Signs of inflammation or infection
  • Involvement of surrounding tissue (paronychia)
• Obtain bacterial/fungal cultures if infection is suspected 1
• Consider dermoscopy for better visualization of nail changes 2

Common Causes

1. Trauma/Mechanical factors:

   • Manicuring, occupational trauma, self-induced behavior
   • Pressure from ill-fitting shoes (especially in toenails) 3

2. Dermatological conditions:

   • Psoriasis and pustular psoriasis (most common disease-related cause) 3
   • Atopic dermatitis 4

3. Infections:

   • Fungal (dermatophytes, molds, yeasts) 5
   • Bacterial (particularly Pseudomonas with greenish discoloration)

4. Medication-related:

   • Taxane chemotherapy agents 1
   • Phototoxic reactions to medications 3

5. Simple onycholysis - not associated with systemic disease, infections, or primary dermatological conditions 6

Management Approach

General Principles

• Treatment depends on clinical grading and impact on activities of daily living 1
• Early intervention is crucial to promote nail reattachment and prevent permanent damage 1

Grade-Based Management Algorithm

Grade 1 (Mild) Onycholysis:

• Keep nails short, clean, and dry (use hair dryer to dry nail area) 3
• Avoid trauma, water immersion, and irritants
• Obtain bacterial/viral/fungal cultures if infection is suspected
• If infection present, begin appropriate antimicrobial therapy
• Reassess after 2 weeks; if worsening, proceed to next level of care 1

Grade 2 (Moderate) Onycholysis:

• Continue all measures for Grade 1
• Obtain cultures if infection suspected
• For painful haematoma or subungual abscess, partial or total nail avulsion is required
• If infection confirmed, use oral antibiotics with anti-staphylococcal and gram-positive coverage
• Reassess after 2 weeks; if worsening, consider treatment interruption of any causative medications 1

Grade 3 (Severe) or Intolerable Grade 2 Onycholysis:

• Interrupt any causative medications until severity decreases
• Obtain cultures if infection suspected
• For painful haematoma or subungual abscess, perform partial or total nail avulsion
• Clean nail bed and treat any infection with appropriate antimicrobials
• Reassess after 2 weeks; if no improvement, consider permanent discontinuation of causative agents 1

Specific Management for Different Causes

Trauma-Induced Onycholysis:

• Remove the cause (ill-fitting shoes, manicuring habits)
• Keep nails short and clean
• Protect nails with cotton gloves for manual work 1

Medication-Induced Onycholysis (e.g., Taxanes):

• Preventive measures: topical emollients, protective nail lacquers, cotton gloves
• For taxane therapy, consider frozen gloves/socks (10-30°C for 90 minutes) during infusion 1
• In severe cases, consider dose modification or drug interruption

Infection-Related Onycholysis:

• For fungal infections: appropriate antifungal therapy based on culture results
• For bacterial infections: targeted antibiotics based on culture and sensitivity
• Regular nail trimming to remove separated portions 1

Psoriasis-Related Onycholysis:

• Treat underlying psoriasis with appropriate therapies
• Consider intralesional steroid injections for isolated nail involvement

Prevention of Recurrence

• Maintain good nail hygiene
• Avoid trauma to nails
• Use protective measures (gloves, appropriate footwear)
• Treat underlying conditions promptly
• Regular follow-up to monitor for early signs of recurrence

Key Pitfalls to Avoid

1. Treating presumed fungal infection without confirmatory testing
2. Ignoring underlying causes (psoriasis, medication effects)
3. Failing to obtain cultures when infection is suspected
4. Delaying nail avulsion when indicated for painful haematoma or abscess
5. Assuming Candida as the primary cause in fingernail onycholysis (often just a colonizer) 3
6. Neglecting to address mechanical factors in toenail onycholysis 3