What is the recommended procedure for fingernail removal?

Fingernail Removal: Recommended Procedure

Fingernail removal should be performed using surgical avulsion under local anesthesia, reserved primarily for severe/refractory ingrown nails, painful hematomas, subungual abscesses, or when diagnostic access to the nail bed is required—not as routine treatment for conditions like onychomycosis. 1, 2

Primary Indications for Fingernail Removal

Nail removal is indicated in specific clinical scenarios:

• Severe or recurrent ingrown nails that have failed conservative management (antiseptic soaks, topical steroids, splinting techniques) 3, 1
• Painful subungual hematoma or abscess requiring drainage and decompression 4
• Dense white dermatophytomas (compact fungal masses beneath the nail that prevent antifungal drug penetration) 1, 2
• Diagnostic purposes when exploration of the nail bed, matrix, or nail folds is necessary before biopsy 5, 6
• Malignant or premalignant lesions of the nail apparatus (e.g., squamous cell carcinoma in situ) where complete excision with histological control is required 4

Important caveat: Complete nail avulsion for onychomycosis showed disappointing results in randomized controlled trials and is NOT recommended as routine treatment 1, 2. Debridement alone cannot be recommended as definitive therapy 1.

Surgical Technique

Anesthesia

• Administer local anesthesia with 1% ropivacaine or lidocaine (with or without epinephrine 1:200,000 dilution) 5, 6
• Use digital nerve block for complete nail procedures, ensuring the entire operative zone is anesthetized 6, 7
• Minimize injection pain by using the smallest gauge needle, injecting slowly, and buffering the anesthetic to reduce acidity 8, 9
• Allow adequate time for anesthesia onset and vasoconstriction (if epinephrine used) before proceeding 8

Preparation

• Disinfect with isopropyl alcohol scrub followed by chlorhexidine 6
• Mark planned incision lines precisely before injection to avoid distortion from tissue expansion 8
• Obtain bacterial/viral/fungal cultures if infection is suspected 4

Avulsion Procedure

• Surgical avulsion using the distal approach is most commonly performed 5
• For partial removal: Remove only the affected lateral portion in ingrown nails 3, 1
• For complete removal: Elevate the entire nail plate from the nail bed, taking care to preserve underlying structures 5, 6
• Clean and culture the nail bed at the time of removal 4
• For associated granulation tissue, perform scoop shave removal with hyfrecation or apply silver nitrate 3, 1

Alternative Methods

• Chemical ablation using 40% urea paste can be considered as a non-surgical alternative 4, 5
• Laser ablation may be used in specific cases (e.g., epidermolysis bullosa patients) 4

Post-Procedure Management

Immediate care:

• Initiate oral antibiotics with anti-Staphylococcus aureus and gram-positive coverage if infection is present 4
• Continue antiseptic soaks with dilute vinegar (50:50 dilution) or 2% povidone-iodine twice daily for 10-15 minutes 3
• Apply mid to high-potency topical steroid ointment to nail folds twice daily to reduce inflammation 3

Follow-up:

• Reassess wound healing at 2 weeks post-procedure 3
• Monitor for signs of infection (increased pain, redness, swelling, purulent drainage) 3
• Cut nails regularly and straight across until the nail plate grows reattached 4

Prevention of Recurrence

After nail removal and regrowth:

• Trim nails straight across, not too short, to prevent ingrowth 3
• Apply daily topical emollients to cuticles and periungual tissues 3
• Avoid trauma by wearing comfortable, well-fitting shoes 3
• Avoid cutting cuticles or manipulating nail folds 3
• Wear protective gloves when working with water or chemicals 3

Critical Pitfalls to Avoid

• Do not perform complete nail avulsion routinely for fungal infections—evidence shows disappointing results 1, 2
• Exhaust conservative measures first in drug-induced nail toxicities (cancer patients) before considering removal 1
• For granulation tissue, perform scoop shave removal rather than complete nail removal 1
• In diabetic patients, assess vascular status and infection risk before any nail procedure, and consider alternative interventions like flexor tendon tenotomy for at-risk feet 2
• Ensure procedures are performed only by appropriately trained healthcare professionals with proper surgical skills 2, 6