Treatment for Nail Avulsion
The standard treatment for nail avulsion involves careful nail removal, meticulous cleaning and repair of the nail bed, followed by appropriate management of any associated complications such as infection or hematoma. 1
Initial Assessment and Management
- Nail avulsion may be performed for diagnostic purposes (exploration of nail bed, matrix, and folds) or therapeutic purposes (onychocryptosis, warts, onychomycosis, chronic paronychia, nail tumors) 2
- Local anesthesia should be administered for pain control before the procedure 1
- The procedure is typically carried out under local anesthesia with or without epinephrine (1:200,000 dilution) 2
Repair Technique
- After nail removal, the nail bed must be thoroughly cleaned to prevent infection and promote proper healing 1
- For nail bed lacerations, meticulous repair of the nail bed is essential after cleaning 3
- In cases of partial nail avulsion, the remaining nail should be carefully managed to prevent further complications 2
Infection Prevention and Management
- If pus is present, obtain cultures and initiate appropriate antibiotics with coverage against Staphylococcus aureus and other gram-positive organisms 1
- Daily dilute vinegar soaks (50:50 dilution) to the nail folds twice daily can help reduce inflammation 4, 1
- For edema and pain, mid to high potency topical steroid ointment can be applied to nail folds twice daily 4, 1
Management of Specific Conditions
For Onychomycosis:
- Treatment should not be commenced before mycological confirmation of infection 4
- For dermatophyte infections, terbinafine is superior to itraconazole and should be considered first-line treatment 4
- For candidal onychomycosis with nail plate invasion, itraconazole is most effective (400 mg daily for 1 week per month, repeated for 2 months in fingernail infection) 4
- In treatment-resistant cases, nail removal combined with antifungal therapy can improve outcomes, though results vary 5
For Ingrown Toenails:
- Conservative approaches include soaking the foot in warm, soapy water, placing cotton wisps under the ingrown nail edge, and gutter splinting 6
- For recurrent cases, partial nail avulsion combined with phenolization is more effective than surgical excision alone in preventing recurrence 6
- In cases of onychocryptosis, dental floss insertion under the ingrown nail can separate the lateral nail edge from underlying tissue 4
For Pincer Nails:
- Total nail avulsion can be effective for pincer nails, especially on the second and third toes 7
- Post-avulsion taping can help guide the new nail to grow with improved curvature 7
Post-Procedure Management
- Regular nail trimming is necessary until the nail plate grows reattached 1
- Watch for signs of infection including increased pain, redness, swelling, or purulent drainage 1
- For granulation tissue formation, options include scoop shave removal with hyfrecation or silver nitrate application 4
Complications to Monitor
- Chronic onycholysis and persistent subungual hyperkeratosis can develop if the nail is not properly removed when indicated 3
- Recurrence rates vary depending on the underlying condition and treatment approach 6
- In cases of treatment failure for onychomycosis, consider poor compliance, poor absorption, immunosuppression, dermatophyte resistance, or zero nail growth as potential causes 4
Special Considerations
- For recurrent, severe, or treatment-refractory paronychia, doxycycline at 100 mg twice daily can be used with recommended follow-up after 1 month 4
- In cases requiring splinting, a plastic tube with a lengthwise incision can be placed on the lateral edge of the nail 4
- Formable acrylic may be used for fixation of splints and nail prostheses in complex cases 4