What are the causes and treatments for a toenail that suddenly falls off and bleeds?

Sudden Toenail Loss with Bleeding: Causes and Management

A toenail that suddenly falls off with bleeding is most commonly caused by acute trauma (direct injury or repetitive microtrauma from ill-fitting footwear), subungual hematoma with secondary nail plate separation, severe infection (paronychia or abscess), or underlying onychomycosis that has weakened nail plate attachment. 1, 2

Primary Causes

Traumatic Onycholysis

• Direct trauma from dropping objects on the toe, stubbing, or sports injuries can cause immediate nail plate separation with bleeding from the exposed nail bed 1
• Repetitive microtrauma from tight or ill-fitting shoes creates chronic pressure leading to gradual nail loosening and eventual avulsion 2, 3
• Subungual hematoma (blood collection under the nail) can create pressure that forces the nail plate off, often with associated bleeding when the nail separates 1

Infectious Causes

• Severe paronychia (nail fold infection) can progress to subungual abscess formation, causing painful nail separation with purulent and bloody discharge 1, 4
• Onychomycosis (fungal nail infection) weakens the nail plate structure over time, making it susceptible to sudden avulsion with minimal trauma 1
• Secondary bacterial infection (particularly Staphylococcus aureus) can complicate any nail injury and accelerate nail loss 1, 4

Other Contributing Factors

• Onychocryptosis (ingrown toenail) with chronic inflammation can lead to nail plate instability 2, 3
• Hyperhidrosis (excessive sweating) and poor foot hygiene create an environment for nail weakening 3, 5

Immediate Management Algorithm

Step 1: Control Bleeding and Assess Severity

• Apply direct pressure with clean gauze for 10-15 minutes to control bleeding 2
• If bleeding persists beyond 15 minutes or there is severe pain, seek immediate medical attention 1
• Examine for signs of infection: increased warmth, purulent drainage, spreading erythema, or fever 1, 4

Step 2: Wound Care

• Clean the exposed nail bed with dilute antiseptic solution or warm soapy water 2, 4
• Soak the affected toe in warm water with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily 1, 2
• Apply mid to high potency topical steroid ointment to reduce inflammation if no infection is present 1

Step 3: Culture and Antibiotic Decision

• Obtain bacterial/viral/fungal cultures if infection is suspected before starting antibiotics 1
• If infection is present, begin oral antibiotics with anti-Staphylococcus aureus and gram-positive coverage (such as first-generation cephalosporins, amoxicillin-clavulanate, clindamycin, or doxycycline) 1, 4
• Continue topical antiseptic soaks even while on oral antibiotics 1, 2

Step 4: Nail Bed Management

• If a subungual hematoma or abscess is present, partial or total nail avulsion may be required by a healthcare professional 1, 4
• The nail bed must be cleaned and cultured at the time of any surgical intervention 1
• Any remaining loose nail fragments should be trimmed to prevent catching and further trauma 1

Treatment Based on Underlying Cause

If Fungal Infection is Identified

• Do not start antifungal therapy until mycological confirmation (positive microscopy and culture) is obtained 1
• For confirmed dermatophyte onychomycosis, terbinafine is superior to itraconazole and should be considered first-line treatment (250 mg daily for 12 weeks for toenails) 1
• Itraconazole is the alternative (200 mg daily for 12 weeks continuously, or 400 mg daily for 1 week per month for 3 pulses) 1
• For candidal onychomycosis with nail plate invasion, itraconazole 400 mg daily for 1 week per month for 3-4 pulses is most effective 1

If Ingrown Toenail is Contributing

• Correct inappropriate footwear immediately by wearing comfortable, well-fitting shoes with adequate toe box space 2, 3
• For recurrent, severe, or treatment-refractory ingrown toenails, partial or complete nail removal may be indicated after conservative measures fail 2, 6

Prevention of Recurrence

• Trim toenails straight across (not too short and not rounded at corners) to prevent future ingrown nails 1, 2
• Wear properly fitted footwear with 1-2 cm longer than the foot itself and adequate width at the metatarsal phalangeal joints 1, 2
• Apply topical emollients daily to cuticles and periungual tissues to maintain skin barrier function 1, 2
• Avoid walking barefoot indoors or outdoors, and never wear shoes without socks 1
• Manage hyperhidrosis with absorbent powders and cotton socks changed daily 1, 3

Critical Pitfalls to Avoid

• Never start systemic antifungal therapy without mycological confirmation, as treatment failure rates are high and medications have potential adverse effects 1
• Do not debride ischemic or neuro-ischemic wounds without signs of infection, particularly in diabetic patients 1
• Reassess after 2 weeks if the condition worsens or does not improve with initial treatment 1, 4
• In diabetic patients, any toenail problem requires immediate evaluation by an appropriately trained healthcare professional to prevent foot ulceration 2, 6

When to Seek Specialist Care

• Persistent bleeding despite direct pressure 1
• Signs of spreading infection (ascending lymphangitis, fever, systemic symptoms) 1, 4
• Diabetic patients with any nail injury or loss 2, 6
• Suspected subungual abscess or extensive nail bed damage requiring surgical intervention 1, 6
• Treatment failure after 2 weeks of appropriate therapy 1, 4