Nail Removal Indications
Nail removal is indicated for treatment-refractory onychocryptosis (ingrown toenail), dermatophytoma in onychomycosis resistant to antifungal therapy, chronic paronychia with nail irregularities, nail bed exploration for diagnostic purposes, and certain nail tumors. 1, 2
Primary Indications for Nail Removal
Onychomycosis with Dermatophytoma
- Mechanical removal is necessary when dense white lesions (dermatophytomas) develop beneath the nail, as these pockets of tightly packed hyphae resist antifungal treatment without prior removal. 1
- This presentation most commonly affects the great toenail and appears as a compact fungal mass that prevents drug penetration. 1, 3
- Chemical avulsion using 40% urea with bifonazole can be performed once weekly, achieving complete nail removal in approximately 11 days. 4
Onychocryptosis (Ingrown Toenail)
- Partial or complete nail removal is indicated for recurrent, severe, or treatment-refractory ingrown toenails when conservative measures (dental floss splinting, cotton packing, gutter splints) fail. 1
- Scoop shave removal with hyfrecation is recommended for associated granulation tissue. 1
- Matricectomy (permanent nail matrix destruction) may be indicated for recalcitrant cases affecting the lateral one-third of the nail. 5
Chronic Paronychia with Nail Irregularities
- Nail removal combined with eponychial marsupialization is indicated when chronic paronychia presents with concurrent nail irregularities. 6
- Marsupialization alone has a higher recurrence rate (2 of 7 cases) when nail irregularities are present, compared to zero recurrences when combined with nail removal (0 of 16 cases). 6
- For chronic paronychia without nail irregularities, marsupialization alone is sufficient. 6
Diagnostic Indications
Nail Bed and Matrix Exploration
- Nail avulsion is indicated before contemplating biopsy of the nail bed or for exploration of the nail matrix and nail folds. 2
- This allows proper visualization and access for diagnostic procedures when nail pathology requires histological confirmation. 2
Important Caveats and Pitfalls
Onychomycosis Treatment Failure
- Surgical avulsion followed by topical antifungal therapy for single-nail onychomycosis showed disappointing results in randomized controlled trials and is not recommended as routine treatment. 1
- However, mechanical intervention remains necessary specifically for dermatophytoma removal, which is distinct from routine onychomycosis treatment. 1
- The British Association of Dermatologists emphasizes that debridement alone cannot be recommended as treatment for onychomycosis. 1
Drug-Induced Nail Toxicities in Cancer Patients
- For drug-induced acute paronychia and pyogenic granulomas in cancer patients, conservative measures should be exhausted before considering nail removal, including antiseptic soaks, topical steroids, taping, and splinting techniques. 1
- Scoop shave removal is reserved for granulation tissue management, not complete nail removal. 1
Other Conditions Requiring Nail Removal
- Onychauxis (nail thickening), onychogryphosis (ram's horn nail), congenital nail dystrophies, and chronic painful nails may require matricectomy. 5
- Nail tumors and retronychia (nail plate growing into proximal nail fold) are additional indications. 2
- Warts involving the nail apparatus may require avulsion for adequate treatment access. 2