Management of Persistent Subungual Hematoma
For a subungual hematoma that has not resolved after 6 months, drainage of the affected area followed by proper nail care is recommended to relieve pressure, prevent infection, and promote proper nail regrowth. 1
Assessment of the Condition
When evaluating a persistent subungual hematoma:
- Determine if the hematoma is causing pain, pressure, or discomfort
- Check for signs of infection (increased redness, warmth, swelling, purulent discharge)
- Assess whether the nail is growing properly or if growth has been impaired
- Evaluate the extent of the hematoma (partial vs. complete involvement of the nail bed)
- Rule out other conditions like melanoma through careful examination 2
Treatment Options
1. Drainage Procedure (Primary Intervention)
Even for a 6-month old hematoma, drainage may still be beneficial:
Use a sterile fine-gauge needle (29-gauge insulin syringe) for evacuation 3
- Insert the needle close to the nail plate to minimize pain
- Drain blood from under the nail plate through the hyponychium
- This technique is particularly effective for smaller subungual hematomas
Alternative drainage methods:
- Controlled nail trephination using a specialized drill that penetrates the nail plate without damaging the nail bed 4
- Electrocautery device on low setting to create a small hole in the nail
- Heated paperclip (although less precise than other methods)
2. Post-Drainage Care
After drainage, follow these steps:
- Clean the area with antiseptic solution
- Apply topical antibiotics if there's concern for infection
- Keep the area dry and clean
- Monitor for signs of infection
3. Management of Nail Growth Issues
For cases where the nail hasn't grown properly:
- Partial nail avulsion may be necessary to remove the detached portion of the nail plate 1
- Clean the nail bed thoroughly after removal
- Apply topical emollients to the nail bed and surrounding tissues
- Consider topical corticosteroids if inflammation is present
4. Prevention of Complications
To prevent further issues:
- Wear properly fitting shoes with adequate toe box width
- Avoid high heels and pointed shoes that compress the toes
- Apply daily topical emollients to cuticles and periungual tissues
- Keep the affected foot dry and clean
Special Considerations
For Diabetic Patients
- More vigilant monitoring is required due to increased infection risk 1
- Earlier intervention may be necessary
- Keep the area dry to prevent further infection
- Consider lower threshold for oral antibiotics
For Immunocompromised Patients
- More aggressive treatment approach may be needed 1
- Consider earlier use of oral antibiotics
- More frequent follow-up to monitor healing
Follow-Up Care
- Schedule follow-up every 2-4 weeks until resolution 1
- Return immediately if signs of infection develop
- Monitor for complications including:
- Permanent nail deformity
- Secondary infection
- Permanent onycholysis (separation of nail from nail bed)
When to Consider Specialist Referral
Consider referral to a dermatologist or podiatrist if:
- The nail shows no signs of proper regrowth after treatment
- There is persistent pain despite interventions
- The appearance suggests possible melanoma or other nail pathology
- The patient has underlying conditions like diabetes that complicate healing
Prognosis
With proper treatment, most subungual hematomas resolve without long-term complications. However, in cases where the hematoma has been present for 6 months, there may be some permanent changes to the nail structure. Complete nail regrowth typically takes 6-12 months for toenails.