Treatment of Nail Indentations
For nail indentations (Beau's lines, onychomadesis, or other nail matrix disruptions), treatment focuses on identifying and addressing the underlying cause while providing supportive nail care, as the nail plate itself will grow out normally once the inciting factor is removed. 1, 2
Immediate Assessment and Supportive Care
Begin daily antiseptic soaks with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily to prevent secondary infection and maintain nail hygiene. 3, 4
- Apply topical emollients daily to the cuticles and periungual tissues to maintain the skin barrier and support healthy nail growth 5, 3
- Protect the affected nail from further trauma by wearing comfortable, well-fitting shoes and avoiding activities that stress the nail unit 5
Identify and Address Underlying Causes
The critical step is determining what caused the nail matrix disruption:
- Medication-related: If the indentation appeared after chemotherapy (particularly taxanes), the nail will normalize once treatment is completed or dosing is adjusted 5
- Trauma-related: Ensure no ongoing mechanical stress or repeated microtrauma to the nail matrix 6
- Systemic illness: Beau's lines can indicate recent severe illness, nutritional deficiency, or metabolic disturbance requiring medical evaluation 1, 2
Management of Complications
If the indentation has progressed to onychomadesis (complete nail plate separation), the loose nail plate should be trimmed back carefully to prevent catching and further trauma. 7, 2
- Obtain bacterial/viral/fungal cultures if signs of infection develop (erythema, purulent drainage, increased pain) 5
- For secondary infection, initiate antibiotics targeting Staphylococcus aureus and gram-positive organisms 3, 4
- Apply mid- to high-potency topical corticosteroid ointment twice daily if significant inflammation of the nail fold develops 3, 4
Prevention of Further Damage
Educate patients to trim nails straight across and not too short, avoid nail manipulation or biting, and wear protective gloves when working with water or chemicals. 5, 3
- Avoid artificial nails and harsh nail products during the recovery period 3
- Consider biotin supplementation to improve nail strength during regrowth, though evidence is limited 5
- For patients on chemotherapy, frozen gloves during infusion can prevent nail toxicity (cooling to -10 to -30°C for 90 minutes reduces nail changes from 51% to 11%) 5
Timeline and Monitoring
The indentation will grow out with the nail plate over 4-6 months for fingernails and 12-18 months for toenails, assuming the underlying cause has been addressed. 1, 8
- Reassess after 2 weeks to ensure no worsening or development of complications 5
- If pain, drainage, or inflammation persists beyond 2-4 weeks despite conservative management, consider referral to dermatology 3, 4
Critical Pitfalls to Avoid
Do not confuse simple nail indentations with retronychia (backward nail embedding), which requires different management including possible nail avulsion. 6 Retronychia presents with proximal nail fold inflammation and multiple generations of nail plate beneath the proximal nail fold, whereas simple indentations are transverse grooves without backward embedding 9, 6
For diabetic patients, monitor more aggressively and provide integrated foot care every 1-3 months, as nail abnormalities can progress to ulceration with significant morbidity. 4