What should be the management plan for a patient with onycholysis (nail lifting) and skin irritation after removing press-on artificial nails by soaking in acetone for nearly 1 hour?

Management of Acetone-Induced Onycholysis and Skin Irritation

Immediately discontinue all artificial nail use and acetone exposure, keep the affected nails completely dry, trim the separated nail regularly, and apply mid-to-high potency topical corticosteroid ointment to the inflamed periungual skin twice daily. 1, 2, 3

Immediate Interventions

Eliminate the Causative Agent

• Stop all artificial nail application permanently, as press-on nails and prolonged solvent exposure (like the 1-hour acetone soak) are direct causes of onycholysis and must be avoided to allow nail reattachment. 1, 3
• Avoid any further exposure to acetone, harsh chemicals, solvents, or prolonged water soaking, as these perpetuate nail plate separation from the nail bed. 1, 3

Promote Nail Reattachment

• Keep the onycholytic (separated) area completely dry using a hair dryer after any water exposure, since moisture in the separated space promotes bacterial and fungal colonization and prevents reattachment. 4
• Trim the separated nail plate regularly until it grows back attached to the nail bed—this is critical because chronic onycholysis leads to irreversible nail bed keratinization and permanent subungual hyperkeratosis if not addressed promptly. 1, 2, 3

Treatment of Skin Irritation

Topical Anti-inflammatory Therapy

• Apply mid-to-high potency topical corticosteroid ointment (such as hydrocortisone or stronger formulations) to the inflamed periungual skin and nail folds twice daily to reduce inflammation and edema from the acetone chemical irritation. 2, 5
• Continue topical corticosteroid application for 2-4 weeks or until inflammation resolves. 5

Adjunctive Measures

• Apply topical emollients daily to the cuticles, periungual tissues, and nail plate to restore the moisture barrier damaged by acetone exposure. 1, 3
• Consider dilute vinegar soaks (50:50 dilution with water) twice daily to the nail folds to reduce inflammation and prevent secondary bacterial colonization in the onycholytic space. 6, 2

Infection Surveillance and Management

Monitor for Secondary Infection

• Watch closely for signs of bacterial or fungal superinfection including increased pain, purulent drainage, warmth, progressive redness, or development of subungual abscess. 1, 6, 2
• If infection is suspected, obtain bacterial and fungal cultures from the nail bed and onycholytic space before initiating treatment. 1, 2

Antibiotic Therapy if Infection Develops

• Initiate oral antibiotics immediately with coverage against Staphylococcus aureus and gram-positive organisms if clinical infection is present (first-generation cephalosporins, amoxicillin-clavulanate, clindamycin, or doxycycline). 1, 6, 2
• Apply topical povidone-iodine 2% twice daily if mild infection or colonization is suspected. 1, 2

Nail Avulsion Criteria

• Partial or total nail avulsion is required if a painful subungual hematoma or abscess develops, as these complications will not resolve with conservative management alone. 1, 2, 3
• At the time of avulsion, meticulously clean the nail bed, obtain cultures, and initiate appropriate antibiotics if infection is present. 2

Preventive Nail Care Instructions

Protective Measures

• Wear cotton gloves during any cleaning activities or when handling irritants to protect healing nails. 1
• Avoid using fingernails as tools, nail biting, cutting nails too short, or any trauma to the nail apparatus. 1, 3
• Do not manipulate cuticles or push them back aggressively. 3

Ongoing Maintenance

• Apply protective nail lacquers to limit water loss from the nail plate once acute inflammation resolves. 3
• Trim nails regularly, keeping them straight and not too short, until complete reattachment occurs. 1, 2

Follow-Up Protocol

Reassessment Timeline

• Reassess after 2 weeks (either in-person or via patient self-report) to monitor for worsening inflammation, infection development, or failure to improve. 1, 2
• If the condition worsens or does not improve after 2 weeks of conservative management, consider nail avulsion or escalation of therapy. 1, 2

Long-Term Monitoring

• Continue monitoring until complete nail reattachment occurs, which may take 3-6 months for fingernails depending on the extent of separation. 7
• Failure to promote early reattachment results in permanent onycholysis with nail bed keratinization that cannot be reversed. 2, 3

Critical Pitfalls to Avoid

• Do not delay nail removal if severe pain, subungual hematoma, or abscess develops—this leads to permanent nail bed damage and chronic infection. 2, 3
• Do not assume fungal infection is the primary cause in this acetone-exposure scenario; Candida and other organisms are typically secondary colonizers of the onycholytic space, not the causative agent. 4
• Do not allow continued moisture exposure to the separated nail area, as this perpetuates the problem and prevents healing. 4
• Do not permit return to artificial nails even after healing, as recurrence is highly likely with repeated chemical and mechanical trauma. 1, 3