What is the treatment for blood under the toenail bed?

Treatment of Blood Under the Toenail Bed

For blood under the toenail bed (subungual hematoma), drainage through controlled nail trephination is the recommended treatment to relieve pain and prevent complications. 1, 2

Assessment and Initial Management

• Subungual hematomas are collections of blood under the nail plate that can cause extreme discomfort due to pressure and require prompt intervention 1
• Before treatment, radiographs should be obtained to rule out associated distal phalangeal fractures, which occur with high incidence in traumatic cases 2
• Determine the extent of the hematoma - larger hematomas (>50% of nail bed) or those with nail bed laceration may require more extensive intervention 3

Treatment Options

First-Line Treatment: Drainage Techniques

• Controlled nail trephination is the standard first-line treatment for uncomplicated subungual hematomas 1

  • Create a small hole in the nail plate to allow blood drainage without damaging the underlying nail bed
  • Methods include:
    • Using a heated paperclip or spike (can be performed without local anesthesia even in non-clinical settings) 4
    • Using a specialized drill designed to penetrate the nail plate without breaching the nail bed 1
    • For smaller nails (children, toes 2-5), an extra-fine 29-gauge insulin syringe needle inserted close to the nail plate is an excellent alternative 5, 4

• After drainage, apply gentle pressure to ensure complete evacuation of blood 3

For Complicated Cases

• Nail removal is indicated when there is:

  • Severe pain unrelieved by simple drainage
  • Suspected nail bed laceration
  • Signs of infection or abscess formation 3

• When removing the nail:

  • The nail bed must be thoroughly cleaned
  • Obtain bacterial/fungal cultures if infection is suspected
  • Repair any underlying nail bed laceration 3
  • Treat any identified infection with appropriate antibiotics with anti-staphylococcus aureus and gram-positive coverage 3

Post-Treatment Care

• Soak the affected toe in warm water with Epsom salt solution daily to reduce inflammation and prevent infection 6
• Apply topical antiseptics to prevent secondary infection 3
• For painful inflammation, mid to high potency topical steroid ointment can be applied to nail folds twice daily 3
• Regular nail trimming is necessary until the nail plate grows reattached 3
• Monitor for signs of infection (increasing pain, redness, swelling, discharge) 7

Complications to Watch For

• Patients should be warned about possible complications even with proper treatment:
  • Onycholysis (separation of nail from nail bed)
  • Transient or permanent nail deformity
  • Secondary infection 2
  • Chronic onycholysis and persistent subungual hyperkeratosis if inadequately treated 3

When to Seek Further Care

• If signs of infection develop (redness, warmth, swelling, purulent discharge), prompt evaluation is needed 7
• If pain persists despite drainage, reassessment for underlying nail bed laceration or fracture is warranted 2
• If the nail shows no signs of normal regrowth after several weeks, specialist evaluation may be needed 3