Management of Onycholysis

Initial Assessment and General Principles

The primary goal is to promote nail reattachment as quickly as possible, since chronic onycholysis leads to irreversible nail bed keratinization and persistent subungual hyperkeratosis, according to the American College of Dermatology 1, 2
Management is stratified by clinical severity and impact on daily activities, with the American Academy of Dermatology recommending a severity-based approach 1, 2

For Grade 1 (Mild) onycholysis, continue monitoring while maintaining current activities, with no treatment interruption required, as recommended by the American College of Dermatology 3, 4, 5
For Grade 2 (Moderate) onycholysis, partial or total nail avulsion is required for painful hematoma or subungual abscess, with the American Academy of Dermatology recommending prompt treatment 3, 5
For Grade ≥3 or Intolerable Grade 2 onycholysis, interrupt treatment immediately until severity decreases to Grade 0-1, with the American College of Dermatology recommending a treatment interruption approach 3, 5

Daily use of topical emollients on periungual folds, matrix, and nail plate is recommended by the American Academy of Dermatology to prevent onycholysis 1, 2, 3, 4
Apply protective nail lacquers to limit water loss from the nail plate, as recommended by the American College of Dermatology 1, 2, 3, 4
For taxane-related onycholysis, frozen gloves and frozen socks should be systematically used, reducing nail changes from 51% to 11% in fingernails and from 21% to 0% in toenails, according to the American Society of Clinical Oncology 1, 2, 3, 4

Manipulation of cuticles and nail biting should be avoided, as recommended by the American Academy of Dermatology 1, 2, 3, 4
Using fingernails as tools, prolonged soaking in water, exposure to solvents or harsh chemicals, and application of artificial nails should also be avoided, according to the American College of Dermatology 1, 2, 3, 4

Failing to remove the nail when indicated leads to chronic onycholysis and persistent subungual hyperkeratosis, with the American Academy of Dermatology recommending prompt nail removal 6, 8
Inadequate cleaning and debridement of the nail bed during removal causes complications, according to the American College of Dermatology 6, 8