Nail avulsion is a minor surgical procedure involving the partial or complete removal of a fingernail or toenail. This intervention is often necessary when the nail unit is compromised by injury, chronic disease, or infection, and other treatments have failed. The goal is to alleviate pain, treat underlying pathology, and allow for the healthy regrowth of a new nail plate.
Reasons for Fingernail Removal
Medical necessity for removal arises from conditions that threaten the digit’s health or require access to structures beneath the nail plate. Acute trauma resulting in a subungual hematoma (a collection of blood trapped beneath the nail) is a common reason. If the hematoma covers a large portion of the nail bed, the nail may need removal to inspect and repair underlying tissue for lacerations or fractures.
Chronic, persistent infections often necessitate removal, especially when the nail plate is severely diseased. Extensive onychomycosis, a fungal infection causing the nail to become thickened and discolored, may require avulsion if oral and topical medications fail to penetrate sufficiently. Removing the infected nail plate allows topical medications to be applied directly to the nail bed. Chronic ingrown nails (onychocryptosis) or severe inflammation of the nail fold (paronychia) sometimes require partial or total removal.
Removal may also be performed for diagnostic purposes when a growth or tumor is suspected beneath the nail, such as a cyst or a melanoma. The nail plate is removed to provide clear access for a biopsy of the nail bed or matrix tissue. This allows physicians to accurately identify the underlying problem and determine the appropriate treatment plan. The procedure can also address structural deformities like onychogryphosis, where the nail becomes excessively thickened and curved.
Determining the Right Medical Specialist
The specific professional who performs a nail avulsion depends on the underlying condition, location, and urgency. For chronic conditions, such as severe fungal infections or a suspected tumor, a Dermatologist is often the appropriate specialist. Dermatologists specialize in skin, hair, and nail disorders, frequently performing both surgical and chemical nail avulsions. They are highly skilled in diagnostic procedures like nail matrix biopsies, which require careful removal of the nail to sample the underlying tissue.
When the issue involves the foot, a Podiatrist is the primary specialist for nail removal, particularly for recurrent ingrown toenails. Podiatrists possess surgical training for nail avulsion, and their expertise centers on the biomechanics and pathology of the nail unit. While their focus is primarily on the lower extremities, they may sometimes apply this training to fingernails depending on the case complexity.
Acute, traumatic injuries requiring immediate attention are usually managed by Emergency Room (ER) or Urgent Care physicians. A crush injury resulting in a large, painful subungual hematoma may require immediate partial removal to relieve pressure and examine the nail bed for damage. These physicians are trained to handle time-sensitive trauma and stabilize the injury before referring the patient to a specialist for long-term follow-up. For more complex trauma involving fractures or extensive tissue damage, an orthopedic or hand surgeon may be required.
The Procedure and Post-Removal Care
Nail avulsion begins with local anesthesia to ensure patient comfort. A digital block, where a numbing agent is injected at the base of the finger, is typically used to anesthetize the digit before removal begins. Once numb, the physician uses specialized instruments to carefully separate the nail plate from the underlying nail bed and surrounding skin folds.
Removal can be partial or total, depending on the extent of the pathology. If the goal is to permanently stop the nail from regrowing, a chemical like phenol may be applied to the nail matrix to destroy the cells responsible for nail production. Following removal, the exposed nail bed is cleaned, treated with an antibiotic ointment, and covered with a non-stick dressing.
Post-removal care is important for preventing infection and promoting healthy healing. Patients are instructed to keep the digit elevated for 24 to 48 hours to minimize swelling and pain. The dressing needs regular changes, usually involving a brief soak in warm water or a saline solution to prevent sticking, followed by fresh antibiotic ointment application. Complete healing of the nail bed takes a few weeks, and a new fingernail is expected to regrow over approximately six to nine months.