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

Take a test on this article and claim your certificate on MIMS Learning

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Follow Us:

Just published

Party manifestos offer 'too little too late' on NHS pension tax crisis

Party manifestos offer 'too little too late' on NHS pension tax crisis

Political parties are offering 'too little too late' in their manifestos over the...

GPs report rising workload linked to record hospital waiting times

GPs report rising workload linked to record hospital waiting times

Eight in 10 GPs say rising waits for NHS hospital treatment have driven up workload...

Viewpoint: 'Why the RCGP should not adopt a neutral stance on assisted dying'

Viewpoint: 'Why the RCGP should not adopt a neutral stance on assisted dying'

The RCGP is currently surveying members for their views on assisted dying. In response...

Hurried GP consultations 'a scandal', RCGP chair warns

Hurried GP consultations 'a scandal', RCGP chair warns

Hurried consultations in general practice are 'a scandal that needs to be named'...

GMC labels overseas GP registration 'unfit for purpose' as British doctor denied work

GMC labels overseas GP registration 'unfit for purpose' as British doctor denied work

The GMC has labelled the system for registering overseas doctors as 'unfit for purpose'...

Which parts of England are facing a GP retirement timebomb?

Which parts of England are facing a GP retirement timebomb?

In parts of England more than 40% of the GP workforce in permanent roles is aged...