Differential diagnoses: Painful nails

Dr Nigel Stollery compares four presentations and offers clues for their diagnosis including subungual haematoma, paronychia, pincer nails and subungual viral wart.

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

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