Green Nail Syndrome Treatment
For green nail syndrome (chloronychia), the primary treatment is to trim away the detached nail plate, apply topical antiseptics (2% sodium hypochlorite or povidone iodine 2% twice daily), keep the area dry, and consider oral ciprofloxacin for more severe cases. 1, 2, 3, 4
Immediate Management Steps
Mechanical debridement is essential: Cut away all detached, discolored nail plate to expose the underlying nail bed and remove the reservoir of bacterial colonization. 3, 4
Topical antiseptic therapy: Apply one of the following twice daily:
- 2% sodium hypochlorite solution (bleach) brushed onto the nail bed 3, 4
- Povidone iodine 2% applied to the affected area 1
Moisture control is critical: The nail must be kept completely dry, as Pseudomonas aeruginosa thrives in moist environments. 1, 2, 3, 4
Systemic Antibiotic Therapy
Ciprofloxacin is the empiric oral antibiotic of choice for green nail syndrome when topical therapy alone is insufficient or the infection is more extensive. 2, 5 This targets Pseudomonas aeruginosa, the causative organism in the vast majority of cases. 2, 5, 3, 4
Consider oral antibiotics for:
- Grade 2 or higher severity with significant nail involvement 1
- Cases not responding to topical therapy within 2 weeks 1
- Presence of secondary bacterial superinfection 1
Essential Preventive Measures
Eliminate moisture exposure: Patients must wear cotton gloves underneath latex/rubber gloves for all wet work and household cleaning tasks. 1, 3, 4 This dual-glove approach prevents moisture accumulation while protecting the nail.
Remove predisposing factors:
- Discontinue artificial/acrylic nails immediately, as these are a major risk factor 2
- Avoid nail trauma, manipulation of cuticles, and using nails as tools 1
- Address any underlying onycholysis from other causes (psoriasis, trauma, fungal infection) 3, 4
Daily emollient application to cuticles and periungual tissues helps maintain nail barrier integrity. 1, 6
Diagnostic Considerations
Clinical diagnosis is typically sufficient: The characteristic green-yellow, green-blue, or green-brown discoloration in the appropriate clinical context (moisture exposure, artificial nails, underlying onycholysis) allows diagnosis without laboratory confirmation. 2
Culture nail clippings only if:
- No response to empiric treatment after 2-4 weeks 1, 2
- Atypical presentation requiring differentiation from fungal infection 5, 7
- Need to rule out polymicrobial infection 1, 7
Note that bacterial cultures from nail clippings are specific but not sensitive for Pseudomonas aeruginosa detection. 2 Fungal causes (particularly Candida parapsilosis) can occasionally produce green discoloration and should be considered if bacterial treatment fails. 7
Expected Timeline and Follow-Up
Improvement should be visible within 1 week of initiating treatment, with complete resolution typically occurring in 6-8 weeks as the nail grows out. 2 This timeframe is standard and helps reassure anxious patients.
Reassess at 2 weeks: If no improvement or worsening occurs, obtain bacterial and fungal cultures and consider partial nail avulsion for severe cases. 1
Critical Pitfalls to Avoid
Do not treat without addressing moisture exposure - failure to eliminate wet conditions will result in treatment failure regardless of antimicrobial therapy. 3, 4
Do not assume fungal infection - while up to 25% of cases may have secondary fungal or bacterial superinfection, the primary pathogen is Pseudomonas in typical green nail syndrome. 1, 7
Do not overlook underlying nail disease - Pseudomonas colonizes pre-existing onycholysis from psoriasis, trauma, or other inflammatory conditions that must also be managed. 3, 4