What to do if a toenail falls off?

Management of Toenail Loss

If a toenail has fallen off, keep the nail bed clean and protected, monitor closely for signs of infection, and allow natural regrowth over 12-18 months while addressing any underlying cause such as trauma, fungal infection, or other nail pathology. 1

Immediate Care of the Exposed Nail Bed

• Clean the area thoroughly with saline solution to remove debris and potential contaminants 2
• Protect the exposed nail bed with a sterile dressing to prevent secondary infection and trauma 1
• Assess for signs of infection including erythema, swelling, increased pain, purulent drainage, or warmth around the area 3, 2
• Obtain bacterial and fungal cultures if infection is suspected or if purulent discharge is present before starting any antimicrobial therapy 1, 3

Determine the Underlying Cause

The British Association of Dermatologists emphasizes that nail loss can result from multiple etiologies, and identifying the cause is crucial for preventing recurrence 1:

• Chronic trauma from repetitive injury can result in distal onycholysis leading to nail loss; examination of the nail bed will appear normal if trauma is the sole cause 1
• Fungal infection (onychomycosis) should be suspected if there was preceding nail discoloration, thickening, or friability; direct microscopic examination and culture are essential before initiating antifungal treatment 1
• Bacterial infection, particularly Pseudomonas aeruginosa (causing green or black discoloration) or Staphylococcus aureus, may have preceded nail loss 1, 4
• Other conditions including psoriasis, lichen planus, or subungual malignant melanoma must be considered, especially if multiple nails are affected or if there are associated skin findings 1

Infection Management

If Infection is Present or Suspected

Initiate oral antibiotics immediately with coverage against Staphylococcus aureus and gram-positive organisms if clinical signs of infection are present 3, 2:

• First-line oral antibiotics include first-generation cephalosporins (cefazolin), amoxicillin-clavulanate, clindamycin (if penicillin-allergic), or doxycycline 3, 2
• Duration of therapy: 7 days for cellulitis without bone involvement, 14 days for deeper tissue involvement 2
• Reassess after 2 weeks to determine if the infection has improved; if worsening or no improvement occurs, consider alternative diagnoses or complications 1, 3

If Abscess or Subungual Hematoma is Present

• Partial or total nail avulsion may be required if there is a painful hematoma or subungual abscess 1, 3
• Clean and culture the nail bed at the time of drainage, and treat any identified infection with appropriate topical or oral antibiotics and antiseptics 1

Topical Management

• Daily dilute vinegar soaks (1% acetic acid) can reduce inflammation and edema 3
• Antiseptic agents such as octenidine for bacterial colonization 4
• Topical antibiotics may be considered for localized infection, though oral therapy is preferred for established infection 3, 4

Fungal Infection Treatment (If Confirmed)

Do not commence antifungal treatment before mycological confirmation of infection through positive culture, direct microscopy, or histological examination 1:

For Dermatophyte Onychomycosis

• Terbinafine 250 mg daily is first-line treatment, superior to itraconazole both in vitro and in vivo, with cure rates of 70-80% for toenails 1, 5
• Treatment duration: 12 weeks for toenails (6 weeks for fingernails if affected) 1, 5
• Monitor liver function tests at baseline and during treatment, particularly if continuous therapy exceeds one month 1
• Alternative: Itraconazole 200 mg daily for 12 weeks continuously, or pulse therapy at 400 mg daily for 1 week per month (three pulses for toenails) 1

For Candidal Onychomycosis

• Itraconazole is the most effective agent when the nail plate is invaded, using the same dosage as for dermatophytes (three to four pulses for toenails) 1

For Mold (Non-dermatophyte) Infections

• These account for approximately 5% of UK cases and 20% of North American cases 1
• Suspect mold infection when previous antifungal treatment has failed repeatedly, direct microscopy is positive but no dermatophyte is isolated, and there is no associated skin infection 1
• Treatment may require nail removal in combination with systemic antifungal therapy 1

Expected Timeline for Nail Regrowth

• Toenails require 12-18 months for complete regrowth due to slow growth patterns 1
• Optimal clinical effect from antifungal therapy is seen months after mycological cure due to the time required for outgrowth of healthy nail 5
• Regular monitoring is essential throughout the regrowth period to detect early signs of recurrence or complications 1

Prevention of Recurrence

The British Association of Dermatologists provides specific strategies to prevent reinfection 1:

• Wear protective footwear in public bathing facilities, gyms, hotel rooms, and changing rooms where fungal elements are commonly found 1
• Apply antifungal powders containing miconazole, clotrimazole, or tolnaftate in shoes and on feet 1
• Wear cotton, absorbent socks and change them regularly 1
• Keep nails as short as possible and avoid sharing toenail clippers with family members 1
• Discard old footwear or decontaminate shoes by placing naphthalene mothballs inside and sealing in a plastic bag for minimum 3 days, or spray with terbinafine solution periodically 1
• Treat all infected family members simultaneously, as both onychomycosis and tinea pedis are contagious 1

Common Pitfalls to Avoid

• Do not assume all nail loss is benign trauma; subungual malignant melanoma must be excluded, particularly if there is pigmentation or atypical features 1
• Do not start systemic antifungal therapy without mycological confirmation, as this leads to inappropriate treatment and potential adverse effects 1
• Do not underestimate seemingly minor infections; puncture wounds and nail bed infections can progress to serious complications including osteomyelitis 2
• Do not neglect the nail bed examination; a normal-appearing nail bed after trauma suggests simple mechanical loss rather than infectious or inflammatory pathology 1
• Avoid prophylactic antibiotics for clean wounds without signs of infection, as they are not routinely indicated 3