Management of Subungual Sore in an Elderly Male
Begin with daily antiseptic soaks using 2% povidone-iodine or dilute vinegar (50:50 dilution) for 10-15 minutes twice daily, followed immediately by application of mid- to high-potency topical corticosteroid ointment to the affected nail fold twice daily. 1, 2
Initial Assessment and Diagnosis
The first priority is determining whether this represents an ingrown toenail (onychocryptosis), paronychia/infection, or onychomycosis (fungal infection), as these are the most common subungual pathologies in elderly males 3, 4:
- Look for purulent drainage, erythema, and swelling of the lateral nail fold - if present, this indicates acute paronychia requiring cultures and antibiotics 1, 2
- Examine for granulation tissue on the lateral nail folds, which appears as friable tissue mimicking an ingrown nail 3
- Check for nail thickening, discoloration (yellow-brown), and friable texture - these suggest onychomycosis, which affects nearly 20% of patients over age 60 and up to 50% of those over 70 4, 5
- Assess for trauma history and footwear habits, as repetitive pressure is a common cause in elderly patients 3, 6
Conservative Management Protocol
For Ingrown Nail or Paronychia (Grades 1-2)
Start with antiseptic soaks and topical steroids as first-line therapy 1, 2:
- Perform 2% povidone-iodine or dilute vinegar soaks (50:50 with water) for 10-15 minutes twice daily 1, 2
- Apply mid- to high-potency topical corticosteroid ointment (not cream - ointment provides better penetration) to nail folds twice daily immediately after soaking 1, 2
- Insert dental floss or cotton under the ingrown nail edge to separate the lateral nail from underlying tissue 1, 2
If Purulent Drainage is Present
Obtain bacterial cultures and initiate oral antibiotics with Staphylococcus aureus coverage 1, 2:
- The recommended duration is 5 days, extending if no improvement 2
- Continue antiseptic soaks and topical steroids concurrently 2
- For recurrent or treatment-refractory cases after 2-4 weeks, prescribe doxycycline 100 mg twice daily with follow-up after one month 1, 2
Management of Granulation Tissue
If granulation tissue develops despite topical therapy 1:
- Perform scoop shave removal with hyfrecation or apply silver nitrate for chemical cauterization 1
- Consider adding topical timolol 0.5% gel twice daily under occlusion as adjunctive therapy 3
Evaluation for Onychomycosis
If the nail shows thickening, discoloration, or friable texture, confirm fungal infection before treating 3:
- Obtain potassium hydroxide (KOH) preparation and fungal culture - this is essential as only 50% of dystrophic nails are actually fungal 3, 4
- The most common organism in elderly males is Trichophyton rubrum (90% of cases in North America) 4, 7
Treatment of Confirmed Onychomycosis
Terbinafine 250 mg daily for 12 weeks is the drug of choice for dermatophyte toenail onychomycosis in elderly patients 8, 4, 7:
- Terbinafine demonstrates 70% mycological cure rates and has fewer drug interactions than itraconazole 4
- Check baseline liver function tests (ALT and AST) before starting therapy 8
- The optimal clinical effect occurs months after treatment completion due to time required for healthy nail outgrowth 8, 4
- Adjunct debridement may improve cure rates compared to terbinafine alone 7
Important caveat: In elderly patients, consider comorbidities, polypharmacy, and hepatic/renal function before prescribing systemic antifungals 5. Common adverse effects in the elderly include nausea, sinusitis, arthralgia, and hypercholesterolemia 7.
When to Escalate Care
Refer for surgical intervention if 1:
- Persistent pain or drainage beyond 2-4 weeks despite conservative management
- Grade 3 paronychia (limiting self-care activities)
- Recurrent episodes requiring repeated medical management
Critical warning for elderly patients: Those with diabetes mellitus should be treated aggressively for onychomycosis to prevent secondary bacterial infections, cellulitis, and potential amputation 7, 6, 9.
Prevention of Recurrence
Counsel the patient on these specific measures 1, 2:
- Trim nails straight across, not too short - this is the single most important preventive measure 1
- Wear comfortable, well-fitting shoes with adequate toe box space 1, 2
- Apply topical emollients daily to cuticles and periungual tissues 1, 10
- Avoid cutting cuticles or manipulating nail folds 1
- Consider topical antifungal maintenance therapy 1-3 times weekly if onychomycosis was present 5