Nail Surgery Myths and Truths

March 2020 | Volume 19 | Issue 3 | Original Article | 230 | Copyright © March 2020

Published online February 10, 2020

Jose W. Ricardo MD, Shari R. Lipner MD PhD

Department of Dermatology, Weill Cornell Medicine, New York, NY

Introduction: There is a paucity of randomized trials on nail surgery. Since there are no established guidelines, dermatologists may have false beliefs about best practices in performing nail surgery and post-procedural care.
Methods: We identified five common myths concerning nail surgery. A PubMed search was performed to refute or support these beliefs. Results: We found compelling evidence that refutes these nail surgery myths. We found that epinephrine can be safely used for nail surgery, hydrogen peroxide and tap water is recommended for wound cleansing, prophylactic topical antibiotics should be avoided, calcium alginate, or amniotic membrane dressings are valuable dressing alternatives, and digital dressings have a low risk profile with precise technique. Discussion: Randomized controlled trials for nail surgery are lacking. Data from similar fields may guide dermatologists in performing nail surgery.

J Drugs Dermatol. 2020;19(3): 230-234 doi:10.36849/JDD.2020.4861


Nail surgery training is frequently neglected during dermatology training programs. In a survey-based study of 240 third-year dermatology residents, 58% had performed 10 or fewer nail procedures, 25% observed only, 4% were lectured only, and 1% had no exposure.1 Moreover, 30% stated that they felt incompetent performing nail surgery.1 Furthermore, in another survey-based study of 164 Mohs surgeons, those performing ten or more nail surgeries vs. fewer than 10 during fellowship reported performing on average twice as many nail procedures as attendings.2 These results highlight dermatologists’ lack of comfort in performing nail surgical procedures.

Therefore, it is not surprising that there is a paucity of data and consensus regarding nail surgery and aftercare. Perhaps due to lack of training and up to date literature, many dermatologists often hesitate to perform necessary nail interventions.3,4 A delay in performing nail surgery may have devastating consequences particularly in cases of delayed diagnosis of malignancies.5

The purpose of this review is to analyze the current literature on nail surgery and dispel prevalent myths. We aim to solve common barriers that dermatologists may experience when performing nail surgery.

Myth: Epinephrine is contraindicated for nail surgery. Truth: Epinephrine is not necessary for many nail surgical procedures, especially when using a tourniquet, but it is safe to use.

Nail surgery is typically performed in an outpatient setting with local anesthesia. The nail unit is highly vascularized, and a bloodless field is necessary for procedures. Epinephrine has several benefits when used in conjunction with local anesthetics, including hemostasis, prolonged anesthesia, reduction in anesthetic quantity, decreased systemic anesthetic absorption, and reduced need for a tourniquet for hemostasis.6–8

However, there has been controversy surrounding the use of epinephrine for the digits, given the theoretical risk of ischemia and necrosis. Historically, it has been contraindicated based on speculations and isolated cases.9,10 In a review of digital injection cases 1880-2000, there were 48 cases of digital gangrene and necrosis with local anesthesia, with only 21 involving use of epinephrine and no cases involving the combination of lidocaine and epinephrine.10 In addition, since epinephrine concentrations, hot soaks, tourniquets, tight dressings, and co-morbidities varied, necrosis was most likely multifactorial, and not solely attributed to epinephrine.10

Furthermore, there is sufficient evidence supporting use of epinephrine with local anesthesia for digital surgery. In a prospective study of finger/hand cases injected with lidocaine (n = 2,719) or bupivacaine (n = 391) and epinephrine (1:100,000 or less), there was no infarction, skin necrosis, or tissue loss.11 Similarly, in a retrospective chart review of 1,111 digit/hand surgery cases with lidocaine with epinephrine (1:100,000), there were no cases of gangrene.12