Treatment of Subungual Hemorrhage (Splinter Hemorrhage)
Most subungual hemorrhages require no treatment and resolve spontaneously within weeks to months as the nail grows out. 1, 2
Initial Assessment
When evaluating a subungual hemorrhage, determine:
- Presence of severe pain or pressure: If the hematoma is causing significant discomfort due to pressure buildup, drainage is indicated 3
- Size and acuity: Large, acute hematomas (typically >50% of nail plate) causing pain benefit from decompression 3
- History of trauma: Most cases are traumatic; absence of trauma warrants investigation for underlying causes 1, 4
- Signs of infection: Look for pus, increased warmth, erythema, or purulent drainage requiring antibiotics 5, 6
Treatment Algorithm
For Painful Acute Hematomas with Pressure
Nail trephination (drainage) is the treatment of choice for symptomatic subungual hematomas causing pressure and pain. 3
- Perform controlled nail trephination using a drill or heated instrument to penetrate the nail plate without breaching the nail bed 3
- This provides substantial pain relief within hours 3
- The technique is quick, convenient, and carries minimal risk when performed correctly 3
For Painful Hematomas with Suspected Abscess
If a painful subungual abscess is suspected, partial or total nail avulsion is required. 5, 6
- Remove the nail plate to access and drain the abscess 5
- Culture the nail bed at the time of removal 5
- Treat any identified infection with oral antibiotics targeting Staphylococcus aureus and gram-positive organisms 5, 6
For Asymptomatic or Minimally Symptomatic Hemorrhages
Observation without intervention is appropriate, as spontaneous resolution occurs in 95.2% of cases within 24 weeks. 2
- No special treatment is necessary during the first year 2
- The hemorrhage will grow out with the nail plate over 6-12 months depending on finger vs. toe 1, 2
- Reassure patients that idiopathic splinter hemorrhages can occur in healthy individuals without underlying disease 1, 7
Supportive Care Measures
While awaiting resolution:
- Protect the nail from further trauma by wearing appropriate footwear and avoiding activities that stress the nail 8
- Keep the area clean with gentle washing 8
- Avoid manipulation of the nail or cuticle 5, 8
When to Investigate Further
If hemorrhages are recurrent, multiple, or persist beyond 1 year without clear trauma, investigate for underlying systemic conditions. 4, 2
Associated conditions to consider include:
However, chronic recurrent splinter hemorrhages can occur in healthy individuals without any identifiable systemic disease. 7
Common Pitfalls to Avoid
- Do not perform nail removal for simple subungual hemorrhages: Complete nail avulsion is reserved only for cases with suspected abscess or severe infection 5, 9
- Do not treat empirically with antifungals: Splinter hemorrhages are not fungal infections and will not respond to antifungal therapy 1
- Do not assume systemic disease: Most cases are traumatic or idiopathic in healthy individuals 1, 7, 2
- Avoid aggressive intervention for asymptomatic lesions: The natural history is spontaneous resolution 2