Subungual haematoma
Presentation
- Usually follows either direct trauma or repeated trauma, for example, tight footwear
- Caused by nail bed laceration under the nail plate
- Important to differentiate from subungual melanomas
- No extension of pigment into adjacent cuticle and proximal or lateral nail folds (Hutchinson's sign not present)
- Haematoma will usually move distally over time
Management
- Nail can be trephined to release pressure; no other treatment is required
- With large haematomas, the nail may die and lift off
- If diagnosis is in doubt a biopsy should be undertaken
Paronychia
Presentation
- Common cause of pain
- Most common cause is ingrowing toenails
- May be associated with tight footwear and high heels
- Redness and discharging pus suggest infection, although may be present without infection
Management
- May improve with saline soaking and treatment of underlying cause
- If infection not responding, oral antibiotics may be required
- Podiatry referral may be helpful
- Particular care required in people with diabetes
Pincer nails
Presentation
- Also known as omega or trumpet nails
- Lateral edges of the nail slowly approach each other compressing the nail bed
- Usually affects toenails but can, rarely, affect fingernails
- Hereditary forms exist but no responsible gene yet detected
- Pain often, but not always, reported by patients
Management
- Podiatry treatment advised if symptomatic
- Treatment comprises resection of lateral parts of the nails
- In recurrent cases whole nail may be removed
Subungual viral wart
Presentation
- Unusual cause of pain under a nail
- Cause not always apparent on simple examination
- Dermoscopy can be helpful to detect wart beneath the nail
- Vessels and hyperkeratosis provide clues
Management
- Treatment can be a challenge
- Salicylic acid paint can be applied under the nail
- Applications may be required for many weeks
- If all else fails, removal of the nail, followed by cryotherapy or direct application of salicylic acid to the wart, may be required
Dr Stollery is a GP in Leicestershire
