What are the guidelines for nail avulsion (nail removal) in pediatric (peds) patients?

Nail Avulsion in Pediatric Patients

For pediatric patients requiring nail avulsion, partial nail avulsion with phenolization is the recommended approach for ingrown toenails, while conservative management should be attempted first for mild cases. 1, 2

Assessment and Diagnosis

• Determine severity of nail condition before proceeding with avulsion:

  • Mild: nail edge causing discomfort with minimal erythema
  • Moderate: pain, erythema, edema, and possible drainage
  • Severe: significant pain, pronounced inflammation, infection with purulent drainage, or granulation tissue 1

• Assess for nail matrix damage, which may require partial or complete nail removal to visualize the matrix 1

• Confirm diagnosis before treatment - for fungal infections, obtain mycological confirmation before starting treatment 3

Treatment Algorithm

1. Conservative Management (First-line for mild cases)

• Should be attempted before surgical intervention for mild ingrown toenails 1, 4
• Includes:
  • Warm soaks with antiseptic solution (10-15 minutes, 2-3 times daily)
  • Cotton wisps under the nail edge
  • Proper nail trimming straight across
  • Daily dilute vinegar soaks (50:50 dilution) for paronychia 1

2. Surgical Intervention (For moderate to severe cases or when conservative management fails)

• Anesthesia Technique:

  • Target the palmar and dorsal digital nerves in the distal part of the fingers for less painful anesthesia in pediatric patients 5
  • Local anesthesia with or without epinephrine (1:200,000 dilution) 6

• Recommended Procedure:

  • Partial nail avulsion with phenolization is superior to matrix excision for ingrown toenails, with significantly lower recurrence rates 2
  • For fungal infections, complete nail avulsion may be necessary in cases of treatment failure, particularly with subungual dermatophytoma 3

• Post-Procedure Care:

  • Regular follow-up every 2-4 weeks until resolution
  • Immediate return if signs of infection develop 1
  • Local antibiotics are not necessary after nail avulsion procedures, as they do not reduce signs of infection or recurrence 2

Special Considerations

Fungal Infections

• For candidal onychomycosis with nail plate invasion, itraconazole is the most effective agent 3
• If avulsion is performed due to fungal infection treatment failure, consider systemic antifungal therapy during nail regrowth 3

Diabetic and Immunocompromised Patients

• Require more vigilant monitoring and earlier intervention due to increased infection risk 1
• Lower threshold for oral antibiotics and more aggressive treatment may be necessary 1

Psychological Impact

• Consider psychological effects, especially in adolescents 1
• Nonoperative treatment may be preferable as first-line approach in children and adolescents 4

Complications to Monitor

• Permanent nail deformity
• Secondary infection
• Permanent onycholysis
• Recurrence of ingrown toenail 1

Evidence Summary

• A study of 199 pediatric patients with ingrown toenails found only 3.1% recurrence with nonoperative management compared to 8.1% with surgical intervention, suggesting conservative management as first-line approach 4
• In a randomized clinical trial of 123 patients, phenol application showed significantly better results than matrix excision regarding recurrence after 1 year (p<0.001) 2
• Local antibiotics did not reduce signs of infection or recurrence in surgical nail procedures 2