What is the proper treatment for a crack across the nail bed?

Treatment of a Crack Across the Nail Bed

For a crack across the nail bed, the proper treatment includes warm soaks with antiseptic solutions (such as 2% povidone-iodine), topical antibiotics with steroids for inflammation, and surgical drainage if an abscess is present. 1

Initial Assessment and Management

When evaluating a crack across the nail bed, it's important to determine whether this represents:

• Simple trauma to the nail
• Acute paronychia (infection of the nail fold)
• Onychomycosis (fungal infection)
• Underlying nail bed injury

First-Line Treatment

1. Warm soaks with antiseptic solutions

   • Use 2% povidone-iodine solution twice daily 1
   • Soak for 15 minutes at a time
   • This helps reduce inflammation and prevent infection

2. Topical therapy

   • For inflammation without infection: Apply mid to high-potency topical corticosteroid ointment to nail folds twice daily 1
   • If signs of infection are present: Use topical antibiotics with steroids 1

3. Drainage if necessary

   • If an abscess has formed, surgical drainage is mandatory 1
   • Failure to drain an abscess is a common pitfall in management

Differential Diagnosis Considerations

If Fungal Infection Is Suspected

Laboratory diagnosis is essential before starting antifungal treatment:

• Microscopy to visualize fungal elements
• Culture to identify the species 2

The British Association of Dermatologists emphasizes that incorrect diagnosis is the most common cause of treatment failure in the UK, which is usually made on clinical grounds alone 2. Therefore, proper laboratory confirmation is crucial.

For fungal infections:

• Subungual debris should be taken from the most proximal part of the infection 2
• A dental scraper can be useful for obtaining material 2
• If the nail is onycholytic, cut back the nail and scrape material from both the underside of the nail and the nail bed 2

If Trauma Is the Cause

Repetitive trauma to the nail plate can result in abnormal appearance and distal onycholysis, leading to colonization by infectious pathogens 2. Examination of the nail bed will help differentiate between trauma and infection - the nail bed will appear normal if symptoms are caused by trauma rather than infection, with intact longitudinal epidermal ridges stretching to the lunula 2.

Prevention and Self-Care

To prevent further damage and promote healing:

• Keep hands dry
• Avoid prolonged water exposure
• Wear gloves while cleaning or doing wet work
• Apply daily topical emollients to cuticles and periungual tissues 1
• Proper nail trimming to avoid trauma 1

Follow-up and Monitoring

• Regular follow-up every 2-4 weeks until resolution 1
• Return within 48-72 hours if signs of infection develop 1
• Monitor for complications including:
  • Permanent nail deformity
  • Secondary infection
  • Permanent onycholysis 1

Special Considerations

• Diabetic patients require more vigilant monitoring and earlier intervention due to increased risk of infection 1
• Immunocompromised patients should be especially cautious about infection risk and may require oral antibiotics and more aggressive treatment 1

Common Pitfalls to Avoid

• Failure to drain an abscess when present
• Overuse of oral antibiotics when not indicated
• Neglecting underlying causes in chronic cases
• Inadequate follow-up
• Missing serious underlying conditions 1

Remember that up to 25% of nail injuries may result in secondary bacterial or fungal infections, so proper initial management is crucial for preventing complications 1.