What is the treatment for nail avulsion?

Treatment for Nail Avulsion

For nail avulsion, the primary treatment involves careful nail removal under local anesthesia, meticulous cleaning and repair of the nail bed, obtaining bacterial cultures if infection is suspected, and initiating oral antibiotics with anti-Staphylococcus aureus and gram-positive coverage if infection is present. 1

Immediate Management

Pain Control and Procedure

• Administer local anesthesia before the procedure for adequate pain control 1
• Perform careful removal of the nail plate, particularly when associated with severe/painful lesions, pressure hematoma, or subungual abscess 2
• Clean the nail bed meticulously at the time of removal 2, 1

Infection Assessment and Treatment

• Obtain bacterial, viral, and fungal cultures from the nail bed at the time of avulsion if infection is suspected or pus is present 2, 1
• Initiate oral antibiotics immediately with coverage against Staphylococcus aureus and gram-positive organisms if infection is present 2, 3
• First-line oral antibiotic options include first-generation cephalosporins, amoxicillin-clavulanate, clindamycin, or doxycycline 3, 1

Post-Avulsion Care

Topical Management

• Apply daily dilute vinegar soaks (50:50 dilution) to the nail folds twice daily to reduce inflammation 1
• Use mid to high potency topical steroid ointment to nail folds twice daily for edema and pain control 1
• Apply topical povidone iodine 2% and topical antibiotics/corticosteroids as needed 2

Ongoing Wound Care

• Cut nails regularly until the nail plate grows reattached to prevent permanent onycholysis 2
• Monitor for signs of infection including increased pain, redness, swelling, or purulent drainage 1
• Elevate the affected extremity if swollen to accelerate healing 4

Follow-Up Protocol

Reassessment Timeline

• Reassess after 2 weeks either by healthcare professional or patient self-report 2, 3
• If reactions worsen or do not improve after 2 weeks, treatment interruption or discontinuation may be necessary 2
• For infected wounds, follow up within 24 hours by phone or office visit 4

Duration of Antibiotic Therapy

• 7 days for cellulitis without bone involvement 4
• 14 days for cases with osteochondritis or deeper tissue involvement 4
• 3-4 weeks for synovitis and 4-6 weeks for osteomyelitis if these complications develop 4

Management of Specific Complications

Granulation Tissue

• Perform scoop shave removal with hyfrecation or silver nitrate application if granulation tissue forms 1

Chronic Onycholysis

• Promote nail reattachment as early as possible to prevent nail bed keratinization and persistent subungual hyperkeratosis 2
• Chronic onycholysis may become permanent if not addressed promptly 2, 1

Recurrent or Severe Paronychia

• Consider doxycycline 100 mg twice daily for treatment-refractory cases with follow-up after 1 month 1

Critical Pitfalls to Avoid

• Do not underestimate seemingly minor nail injuries, as they can progress to serious infections including osteomyelitis 4
• Avoid delaying nail removal when indicated (severe pain, hematoma, or abscess present), as this can lead to permanent nail bed damage 2
• Do not commence treatment for suspected onychomycosis before mycological confirmation 1
• Ensure meticulous nail bed repair if lacerations are present to prevent long-term deformity 1, 5