Should a partially lifted nail still attached to the nail bed be removed?

Management of Partially Lifted Nail Still Attached to Nail Bed

A partially lifted nail that is still attached to the nail bed should generally not be removed unless there is evidence of infection, abscess formation, or severe pain that affects daily activities.

Assessment of Nail Condition

When evaluating a partially lifted nail (onycholysis), consider:

• Extent of detachment from the nail bed
• Presence of pain or discomfort
• Signs of infection (redness, swelling, purulent discharge)
• Debris collection under the detached portion
• Underlying cause of the onycholysis

Management Algorithm

1. For Non-Infected Partially Lifted Nail:

• Keep the nail intact if it remains partially attached to the nail bed without signs of infection 1
• Promote nail reattachment as early as possible to prevent permanent onycholysis 2
• Apply topical emollients to the periungual folds, matrix and nail plate daily 2
• Consider protective nail lacquers to limit water loss from the nail plate 2
• Avoid manipulating the cuticles, nail biting, prolonged water exposure, and use of artificial nails 2

2. For Infected or Severely Painful Partially Lifted Nail:

• Remove the nail plate if there is evidence of:

  • Severe and/or painful onycholysis
  • Pressure hematoma formation
  • Subungual abscess
  • Secondary bacterial or fungal infection 2, 1

• Clean the nail bed thoroughly after removal and obtain cultures if infection is suspected 2

• Apply appropriate antimicrobial treatment based on suspected pathogen 1

Rationale for Decision-Making

The decision to remove or preserve a partially lifted nail depends on several factors:

1. Nail reattachment potential: Early intervention to promote reattachment is crucial as chronic onycholysis may lead to permanent nail bed keratinization and persistent subungual hyperkeratosis 2

2. Infection risk: The detached portion of the nail can collect debris and develop secondary bacterial or fungal infections 2

3. Pain and functionality: Severe pain or functional impairment may necessitate nail removal 2

4. Underlying cause: Treatment should address the underlying cause of onycholysis (trauma, infection, dermatological conditions) 2

Important Considerations

• Removal of the nail should be performed carefully to avoid further trauma to the nail bed 3
• After nail removal, the nail bed must be cleaned and cultured if infection is suspected 2
• Nail bed injuries have generally good outcomes (90% good to excellent results) when properly managed 4
• Poor outcomes are more common with crush injuries, avulsion injuries, and associated infections 4

Prevention of Further Complications

• Keep the affected area clean and dry
• Avoid trauma to the nail
• Use protective gloves when performing wet work
• Apply daily topical emollients to cuticles and periungual tissues 1
• Monitor for signs of infection requiring prompt intervention

Follow-Up

• Regular monitoring until complete healing
• If the nail is removed, a new nail will typically grow in 6 months for fingernails and 12 months for toenails 2
• Watch for signs of permanent nail deformity, which may occur with improper management 1