What are the indications for nail removal in a patient with a wound, particularly in cases with a high risk of infection or impaired wound healing, such as those with diabetes or a history of trauma?

Indications for Nail Removal in Wounds

Nail removal is indicated when there is severe or painful onycholysis, presence of a subungual abscess or pressure hematoma, or when the nail plate prevents adequate drainage and treatment of underlying infection. 1

Primary Indications for Nail Removal

In Taxane-Related Onycholysis (Oncology Context)

• Partial or total nail avulsion is required when Grade 2 or higher onycholysis is accompanied by painful hematoma or suspected subungual abscess 1
• Remove the nail plate when severe and/or painful lesions develop that impact activities of daily living 1
• Nail removal becomes necessary to prevent permanent onycholysis and chronic nail bed keratinization if early reattachment is not promoted 1
• At the time of removal, the nail bed must be cleaned and cultured, with any identified infection treated promptly with appropriate topical or oral antibiotics and antiseptics 1

In Diabetic Foot Infections

While the diabetic foot infection guidelines do not specifically address nail removal, they provide clear surgical principles that apply:

• Urgent surgical intervention is necessary for deep abscesses, compartment syndrome, and necrotizing soft tissue infections 1
• Surgical debridement should remove all devitalized and infected tissue, drain deep pus collections, and decompress foot compartments 1
• Any wound with necrotic tissue or surrounding callus requires debridement, which may range from minor to extensive 1
• Sharp debridement is generally preferable and can be performed as a clinic or bedside procedure, especially in neuropathic feet 1

Specific Clinical Scenarios Requiring Nail Removal

Infection-Related Indications

• Subungual abscess formation requiring drainage 1, 2
• Deep tissue infection where the nail plate prevents adequate access for debridement 1
• Chronic paronychia not responding to conservative management 3
• Osteomyelitis of the distal phalanx where bone exploration or biopsy is needed 1

Trauma-Related Indications

• Nail puncture wounds with subsequent deep infection, particularly when Pseudomonas aeruginosa is suspected or confirmed 4, 5
• Extensive nail bed injury requiring exploration and repair 2
• Pressure hematoma causing severe pain or risk of infection 1

Important Clinical Considerations

When to Avoid Nail Removal

• Do not debride dry eschar on ischemic feet, especially the heel, until it softens or unless underlying infection is apparent 1
• Herpetic whitlow may mimic bacterial abscess but requires non-operative treatment; surgical intervention can cause sequelae 2
• Less severe bacterial infections may respond to conservative management without nail removal 2

Procedural Requirements

When nail removal is performed:

• Obtain bone and tissue specimens for culture and histology if osteomyelitis is suspected 1
• Clean and culture the nail bed at the time of removal 1
• Treat any identified infection with appropriate antibiotics based on culture results 1
• Ensure adequate arterial perfusion before extensive debridement in diabetic or ischemic limbs 1

High-Risk Populations

For patients with diabetes or impaired wound healing:

• Assess for peripheral arterial disease (PAD) using ankle-brachial index (ABI) before surgical intervention 1
• Evaluate for neuropathy and loss of protective sensation 1
• Consider vascular consultation if ABI is abnormal or pedal pulses are diminished 1
• Coordinate care through a multidisciplinary foot care team when available 1

Post-Removal Management

• Nails should be cut regularly until the nail plate grows reattached 1
• Continue appropriate wound care with daily inspection and moist wound-healing environment 1
• Implement off-loading strategies to remove pressure from the affected area 1
• Monitor closely for signs of persistent or recurrent infection 1