Nail Removal

Finger nails are used for scratching, in defense, and, more obviously, to pick up small objects. However, the nail also protects the fingertip, contributes to tactile sensation, and plays an important role in the regulation of peripheral circulation. An abnormal nail is both a cosmetic and functional problem in that it catches on objects, particularly cloth, and causes finger pain and damage to the object. Also see the article Ingrown Toenail Removal.

Nail deformities that require nail removal can occur secondary to anything that causes injury or deformation of the nail bed. This may include infection, ^[1] self-mutilation, tumor, or trauma, as in the following ^{[2, 3, 4]} :

• Onychocryptosis (ingrown nail) ^[5]

• Onychogryposis (deformed, curved nail)

• Subungual elastofibroma ^[6]

• Onychomycosis (fungal infection of the nail) ^[7] (see the image below)

  Candidal onychomycosis in a patient with chronic mucocutaneous candidiasis. Total onychomycosis and paronychia. Image courtesy of Dr Antonella Tosti.

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• Chronic recurrent paronychia (inflammation of the nailfold) ^[8] (see the image below)

  Typical appearance of paronychia.

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Contraindications are as follows:

• Allergy to local anesthetics (relative contraindication)

• Bleeding diathesis

Although many procedures like nail removal can be carried out safely under local ring block, some patients may opt for general anesthesia. The following anesthetic procedures are commonly used:

• Local ring block (For more information, see Local Anesthetic Agents, Infiltrative Administration.)

• Procedural sedation (This may be considered but generally should not be required.)

Equipment includes the following:

• Surgical preparatory supplies

• Syringe, 5 mL

• Needle, 27 gauge (ga)

• Local anesthetic without epinephrine

• Finger tourniquet (eg, rubber band, small Penrose drain, or the finger part of a glove)

• Iris scissors or small Kutz periosteal elevator (nail elevator)

• Straight hemostats (2)

• Nonadherent gauze and tubular gauze dressing

Position the patient supine.

Abduct the arm.

Place the hand on an arm extension with the palm facing down.

Scrub and drape the finger in a sterile fashion.

Administer local anesthetic to ring-block the finger.

Confirm that anesthesia is achieved (wait 5-10 min).

Use a straight hemostat to firmly secure a finger tourniquet around the base of the finger.

Insert the blades of curved Iris scissors or a small periosteal elevator beneath the free edge of the nail (hyponychium). Gently open and close the Iris scissors blades or gently press the nail bed with the small periosteal elevator. Advance proximally in between the nail plate and the nail bed until the instrument reaches the nail fold.

Take appropriate care to avoid any further damage to the nail bed or overlying nail fold during this process.

Once the nail is sufficiently separated from the nail bed, it is gently removed by applying firm and steady distal traction using a hemostat.

Apply a tourniquet at the base of the finger to minimize bleeding.

Take appropriate care to avoid any further damage to the nail bed or overlying nail fold during nail removal.

For onychomycosis, chemical avulsion of the nail may be considered in place of surgical nail removal. A once weekly application of 40% urea and 1% bifonazole has been recommended. ^[9]  

Complications can include the following:

• Bleeding

• Infection

• Nail bed injury

• Nail matrix injury

• Paronychial injury