Treatment of Onycholysis
The treatment of onycholysis requires identifying and addressing the underlying cause, keeping nails short, clean, and dry, and implementing targeted interventions based on severity to prevent permanent nail damage. 1
Causes and Assessment
Onycholysis can result from various causes:
- Trauma or mechanical factors
- Fungal infections
- Chemical exposures
- Medications (particularly taxanes)
- Underlying dermatological conditions (psoriasis, atopic dermatitis)
Treatment Algorithm
Step 1: Address the Underlying Cause
- Remove mechanical factors (ill-fitting shoes, manicuring habits)
- Discontinue irritant exposures
- Manage underlying dermatological conditions
- Consider medication adjustments if drug-induced
Step 2: Basic Management for All Cases
- Keep nails short, clean, and dry
- Avoid trauma and water immersion
- Protect nails with cotton gloves during manual work
- Apply topical emollients to periungual folds and nail plate
- Use protective nail lacquers to limit water loss from nail plate 2, 1
Step 3: Severity-Based Management
Mild Onycholysis (Grade 1)
- Continue basic management
- Obtain bacterial/viral/fungal cultures if infection is suspected
- If infection confirmed, begin appropriate antimicrobial therapy:
- For bacterial infections: oral antibiotics with anti-staphylococcal coverage
- For fungal infections: appropriate antifungal therapy based on culture results
- Reassess after 2 weeks 2
Moderate Onycholysis (Grade 2)
- Continue basic management
- Obtain cultures if infection suspected
- For painful hematoma or subungual abscess, partial or total nail avulsion is required
- If infection confirmed, begin targeted antimicrobial therapy
- Reassess after 2 weeks; if worsening, consider interrupting causative medications 2
Severe Onycholysis (Grade 3 or intolerable Grade 2)
- Interrupt any causative medications until severity decreases
- Obtain cultures if infection suspected
- Perform partial or total nail avulsion for painful hematoma or subungual abscess
- Clean nail bed and culture at the same time
- Treat any infection with appropriate antimicrobials
- Reassess after 2 weeks 2
Special Considerations for Fungal Onycholysis
If fungal infection (onychomycosis) is confirmed:
For Limited Involvement (<50% of nail without matrix)
- Topical antifungal therapy:
For Extensive Involvement (>50% or matrix involvement)
- Oral antifungal therapy:
- Consider combination therapy (oral + topical) for better outcomes 5
Prevention for Taxane-Induced Onycholysis
For patients receiving taxane chemotherapy:
- Frozen gloves (10-30°C for 90 minutes) during infusion
- Frozen socks for toenail protection
- Daily use of topical emollients and protective nail lacquers
- Avoid nail manipulation, prolonged water soaking, and artificial nails 2
Follow-up and Monitoring
- Regular assessment of nail reattachment
- Early intervention for any signs of infection
- Continued nail hygiene and protection
- Monitor for recurrence after successful treatment 1
Common Pitfalls to Avoid
- Failure to identify and address the underlying cause - Treatment will fail if the primary cause persists
- Misdiagnosis of colonization as infection - Candida is often recovered from onycholytic space but may be colonization rather than infection 6
- Inadequate treatment duration - Nail growth is slow, requiring patience and persistence with therapy
- Neglecting nail hygiene - Regular trimming and keeping the area dry are essential components of treatment
- Delayed intervention - Early treatment is crucial to prevent permanent nail damage 2, 1