What is the best practice to relieve pressure under the nail, should I poke a hole in it?

Management of Pressure Under the Nail

For subungual hematoma (blood under the nail), creating a small hole in the nail is the recommended treatment to relieve pressure and pain.

Diagnosis of Pressure Under the Nail

When pressure builds up under the nail, it's typically due to one of the following conditions:

• Subungual hematoma: Blood collection under the nail following trauma
• Paronychia: Infection of the nail fold causing pressure and pain
• Nail bed abscess: Collection of pus under the nail

Clinical Assessment

• Check if the discoloration is reddish-black (blood) or yellowish (pus)
• Assess for pain, throbbing sensation, and tenderness
• Look for signs of infection (redness, warmth, swelling)
• Determine if the injury is recent (acute) or longstanding

Treatment Approach for Subungual Hematoma

When to Drain

• If the hematoma covers >25% of the nail
• If there is significant pain due to pressure
• If the injury occurred within the past 48 hours

Drainage Techniques

1. Controlled Nail Trephination (preferred method):

   • Use a hand-held cautery device to burn a small hole through the nail plate 1, 2
   • Benefits: Precise, painless, minimal risk of nail bed injury
   • The fine tip creates a small hole that allows blood to drain while minimizing complications

2. Alternative Methods:

   • Sterile needle: Rotate gently through the nail plate
   • Paper clip: Heat until red hot, then touch to nail surface
   • Specialized drill device that stops before reaching the nail bed 1

Post-Drainage Care

• Apply antiseptic solution after drainage
• Keep the area clean and dry
• Monitor for signs of infection

Management of Other Nail Pressure Conditions

For Paronychia

• Warm soaks with antiseptic solutions (2% povidone-iodine) 3
• Topical antibiotics with steroids for inflammation 3
• Surgical drainage if abscess is present 3, 4

For Chronic Nail Issues

• Keep hands and feet dry 3
• Avoid prolonged water exposure 3
• Apply daily topical emollients to cuticles 3
• Proper nail trimming to avoid trauma 3

Cautions and Special Considerations

• Do not attempt drainage if:

  • You suspect a nail fracture or significant nail bed injury
  • There are signs of spreading infection
  • The patient has diabetes or is immunocompromised

• Seek medical attention if:

  • Pain persists after drainage
  • Signs of infection develop (increasing redness, warmth, swelling)
  • The patient has underlying conditions like diabetes

Follow-up

• Relief should be immediate after successful drainage
• Monitor for 48-72 hours for signs of infection
• If pain persists or infection develops, seek medical attention

Remember that proper drainage of subungual pressure provides significant pain relief and prevents potential complications like permanent nail deformity or secondary infection.