Subungual Hematoma: Causes, Symptoms, and Effective Treatments

Introduction

A subungual hematoma is a common injury where blood collects beneath a fingernail or toenail, typically due to trauma. This condition can cause significant pain and discomfort as pressure builds under the nail. Subungual hematomas often result from accidents, such as dropping a heavy object on the foot or catching a finger in a door. Traditionally, these injuries have been treated with simple procedures to relieve pressure, but modern telemedicine now allows patients to consult healthcare providers from the comfort of their homes.

This article provides a comprehensive overview of subungual hematomas, covering risk factors, symptoms, diagnostic tests, medications, procedures, and home remedies to manage the condition. Our goal is to help you understand what to expect if you develop a subungual hematoma and how to care for it effectively.

What is a Subungual Hematoma?

A subungual hematoma occurs when blood pools under the nail, often due to trauma. This article will discuss risk factors, symptoms, diagnostic tests, medications, treatment procedures, and home remedies to alleviate symptoms.

Description of Subungual Hematoma

A subungual hematoma forms when blood accumulates beneath the nail plate, usually following an injury that damages the small blood vessels under the nail. This can affect both fingernails and toenails. The trapped blood creates pressure, leading to pain, swelling, and nail discoloration, which can appear dark red, purple, or black, depending on the severity of the injury.

Most subungual hematomas result from blunt trauma, such as hitting your finger with a hammer or stubbing your toe. However, repetitive minor trauma, like running in tight shoes, can also cause this condition. Without treatment, the pressure from pooled blood can cause the nail to separate from the nail bed, and in some cases, the nail may fall off entirely.

Subungual hematomas are common, especially among athletes and individuals engaged in manual labor. Medical studies estimate that subungual hematomas account for 15-20% of all nail-related injuries. While painful, most cases are not serious and can be treated with simple procedures to relieve pressure and reduce pain.

Risk Factors for Developing a Subungual Hematoma

Lifestyle Risk Factors

Certain lifestyle habits and activities increase the risk of developing a subungual hematoma. Individuals involved in high-impact sports like running, soccer, or basketball are more likely to experience trauma to the toes or fingers, leading to this condition. Similarly, those working in manual labor jobs, such as construction or carpentry, face a higher risk due to potential injuries involving heavy tools or machinery.

Wearing ill-fitting shoes, especially those that are too tight, can also increase the likelihood of developing a subungual hematoma. Constant pressure on the toes during activities like running or hiking can cause repetitive trauma to the nail bed. Additionally, frequent use of hands for tasks like typing or playing musical instruments may lead to minor injuries that can result in subungual hematomas.

Medical Risk Factors

Certain medical conditions can make individuals more susceptible to subungual hematomas. For example, people with peripheral vascular disease or diabetes may have compromised circulation, making it easier for blood to pool under the nail after minor trauma. Similarly, individuals on blood-thinning medications, such as aspirin or warfarin, may experience more significant bleeding under the nail following an injury.

Individuals with brittle nails or other nail disorders may also be more prone to subungual hematomas. Conditions like psoriasis or fungal infections can weaken the nail structure, increasing the risk of injury. It’s important to be aware of these underlying conditions, as they may affect the severity and healing time of a subungual hematoma.

Genetic and Age-Related Risk Factors

Age can also play a role in developing subungual hematomas. Older adults may be more prone to this condition due to reduced skin elasticity and slower healing times. As we age, nails may become more brittle, increasing the risk of injury. Additionally, older individuals are more likely to have underlying health conditions, such as arthritis or poor circulation, which can contribute to subungual hematomas.

While there is no strong genetic predisposition to subungual hematomas, individuals with a family history of brittle nails or other nail disorders may be at slightly higher risk. If you have a genetic tendency toward nail fragility, it’s important to take extra precautions.

Clinical Manifestations of Subungual Hematoma

Pain

Pain is the most common symptom of a subungual hematoma, occurring in 90-95% of cases. The pain results from blood accumulation under the nail, increasing pressure on the sensitive nail bed. This pressure can be intense and throbbing, especially in the first few hours after the injury. The severity of pain often correlates with the hematoma’s size, with larger collections of blood causing more discomfort. Patients may describe the pain as sharp or pulsating, and it can worsen with touch or pressure on the affected nail. Pain typically subsides as the blood is reabsorbed or drained.

Discoloration

Discoloration of the nail is present in nearly 100% of subungual hematoma cases. The trapped blood beneath the nail causes it to appear dark red, purple, or black, depending on the amount of blood and how long it has been present. Over time, the discoloration may change as the blood clots and breaks down. In some cases, the nail may remain discolored until it grows out completely, which can take several months. Discoloration is a key visual indicator of a subungual hematoma and often prompts patients to seek medical attention.

Swelling

Swelling occurs in about 60-70% of patients with subungual hematomas. The swelling is typically localized around the injured nail and results from the body’s inflammatory response to trauma. As blood accumulates under the nail, it can cause surrounding tissues to swell. This swelling may be accompanied by redness and warmth, especially in the first few days after the injury. Swelling can make it difficult to move the affected finger or toe, and in some cases, it may extend beyond the nail bed to the surrounding skin.

Tenderness

Tenderness is reported in approximately 80-85% of cases. It is often felt when pressure is applied to the affected nail, such as when wearing shoes or accidentally bumping the injured finger or toe. Tenderness occurs because the blood trapped under the nail exerts pressure on the sensitive nail bed and surrounding tissues. This symptom usually improves as the blood is reabsorbed or drained, but it can persist for several days after the initial injury.

Pulsating Sensation

A pulsating sensation is experienced by around 50-60% of patients. This sensation occurs due to increased pressure from accumulated blood under the nail, which can compress nerves and blood vessels. Patients often describe this as a throbbing or beating feeling in sync with their heartbeat. The pulsating sensation can be particularly bothersome when the affected area is elevated or when lying down. It typically resolves once the pressure is relieved, either by natural reabsorption of the blood or through medical intervention.

Nail Lifting

Nail lifting, or onycholysis, occurs in about 30-40% of subungual hematoma cases, especially in more severe injuries. As blood accumulates under the nail, it can cause the nail to separate from the nail bed. This lifting can be partial or complete, depending on the extent of the hematoma. In some cases, the nail may eventually fall off, particularly if the hematoma is large or if there is significant trauma to the nail bed. New nail growth will typically replace the lost nail over time.

Blood Accumulation

Blood accumulation under the nail is the defining feature of a subungual hematoma and occurs in 100% of cases. The blood pools beneath the nail due to trauma, such as a crush injury or a heavy object falling on the nail. The amount of blood can vary, ranging from a small dot to covering the entire nail bed. The accumulation of blood increases pressure in the area, leading to pain and other symptoms. The blood may clot over time, and in some cases, it may need to be drained to relieve discomfort.

Pressure Sensation

A pressure sensation is reported by approximately 70-80% of patients. This sensation is caused by the buildup of blood under the nail, creating a feeling of tightness or fullness in the affected area. The pressure can be constant or intermittent and is often relieved by draining the blood. If the pressure is not relieved, it can lead to further discomfort and may increase the risk of complications, such as nail loss or infection.

Nail Bed Injury

Nail bed injury occurs in around 40-50% of subungual hematoma cases, particularly in more severe traumas. The nail bed is the tissue beneath the nail, and it can be damaged when a subungual hematoma forms. Nail bed injuries can range from minor bruising to more significant lacerations or fractures. In some cases, the nail bed may require surgical repair, especially if there is a risk of permanent nail deformity. Nail bed injuries can also increase the risk of infection if not properly treated.

Infection

Infection is a less common complication, occurring in about 5-10% of cases. It can develop if bacteria enter the area through a break in the skin or nail bed. Signs of infection include increased pain, redness, warmth, swelling, and the presence of pus. If an infection occurs, it may require antibiotics or drainage to prevent further complications. In rare cases, untreated infections can lead to more serious conditions, such as osteomyelitis (infection of the bone).

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Treatment Options for Subungual Hematoma

Medications for Subungual Hematoma

Acetaminophen

Acetaminophen is a commonly used over-the-counter pain reliever that helps alleviate mild to moderate pain and reduce fever. While it does not have anti-inflammatory effects, it can still provide relief from the discomfort caused by a subungual hematoma.

It is often recommended for individuals who cannot take NSAIDs due to allergies or gastrointestinal concerns. Acetaminophen is typically a first-line option for managing pain in smaller subungual hematomas.

Pain relief generally begins within 30 minutes to an hour and lasts for four to six hours. However, it does not address swelling or inflammation.

Ibuprofen

Ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), helps reduce pain, inflammation, and swelling. It is frequently used to manage discomfort from subungual hematomas.

Ibuprofen is often preferred when inflammation is present, making it a better choice than acetaminophen for larger or more painful hematomas. It can be taken regularly to control pain and reduce swelling.

Relief typically occurs within 30 minutes to an hour, with effects lasting six to eight hours. Its anti-inflammatory properties may also promote faster healing.

Naproxen

Naproxen, another NSAID, works similarly to ibuprofen by reducing inflammation, pain, and swelling. It is often used for more persistent or severe pain.

Naproxen is typically chosen when ibuprofen is insufficient or when longer-lasting pain relief is needed. It is taken every 12 hours, making it a convenient option for ongoing pain management.

Relief usually begins within one hour, with effects lasting up to 12 hours. Naproxen helps reduce both pain and inflammation, supporting quicker recovery.

Aspirin

Aspirin is an NSAID that reduces pain, inflammation, and fever. However, due to its blood-thinning properties, it is less commonly used for subungual hematomas.

Aspirin is generally not the first choice for treating subungual hematomas, as it may increase the risk of bleeding under the nail. It may be considered in specific cases where other NSAIDs are not suitable.

Pain relief typically occurs within 30 to 60 minutes, but aspirin is not commonly recommended due to the potential for increased bleeding.

Topical Anesthetics

Topical anesthetics, such as creams or gels, are applied directly to the skin to numb the area and reduce pain. They provide temporary relief from the discomfort of a subungual hematoma.

These anesthetics are often used when patients prefer not to take oral medications or when the pain is localized and mild. They are applied to the affected nail and surrounding skin.

Patients can expect immediate, short-term relief, though the effects typically last only a few hours, requiring reapplication.

Antibiotics

Antibiotics are used to treat bacterial infections and are not usually required for subungual hematomas unless an infection is present.

They may be prescribed if the hematoma shows signs of infection, such as redness, warmth, or pus. Oral or topical antibiotics can help prevent the infection from spreading.

When used appropriately, antibiotics can clear infections within a few days to a week, preventing complications like abscesses or nail loss.

Corticosteroids

Corticosteroids are anti-inflammatory medications that reduce swelling and inflammation. They are rarely used for subungual hematomas but may be prescribed in severe cases.

Corticosteroids are typically reserved for advanced cases with significant swelling or inflammation. They can be administered orally or topically, depending on the severity.

Patients can expect a reduction in swelling and pain within a few days, but corticosteroids are not a common treatment for subungual hematomas.

Analgesics

Analgesics are medications designed to relieve pain, ranging from over-the-counter options like acetaminophen to stronger prescription medications.

They are often used to manage pain in moderate to severe subungual hematomas. The choice of analgesic depends on the severity of the pain and the patient’s medical history.

Pain relief typically occurs within 30 minutes to an hour, depending on the type of analgesic. Stronger prescription analgesics may provide longer-lasting relief.

Antiseptics

Antiseptics prevent infection by killing or inhibiting bacterial growth. They are often used to clean the affected area before or after a procedure.

Antiseptics are commonly applied before draining a subungual hematoma to reduce the risk of infection. They can also be used at home to keep the area clean and prevent complications.

When used properly, antiseptics significantly reduce the risk of infection, especially after procedures like drainage or nail avulsion.

Pain Relievers

Pain relievers, including NSAIDs and acetaminophen, help alleviate discomfort.

They are the most common treatment for subungual hematomas, especially in mild to moderate cases. Pain relievers are often the first line of defense and can be taken as needed.

Patients can expect relief within 30 minutes to an hour, with effects lasting several hours, depending on the type of pain reliever used.

Procedures for Subungual Hematoma

Drainage (Trephination)

Drainage, or trephination, involves creating a small hole in the nail to release trapped blood and relieve pressure.

This procedure is typically performed when a subungual hematoma covers more than 25% of the nail or causes significant pain. It can be done in a medical office using a sterile needle, cautery device, or laser.

Patients usually experience immediate pain relief after drainage, and the nail often heals within a few weeks. The procedure can prevent complications like nail loss.

Nail Avulsion

Nail avulsion is the surgical removal of part or all of the nail. It is used in severe cases where the nail is significantly damaged or infected.

Nail avulsion is typically reserved for cases where the subungual hematoma has caused extensive damage to the nail bed or when there is a high risk of infection. The procedure is performed under local anesthesia.

After nail avulsion, healing can take a few weeks to months, depending on the extent of the damage. A new nail will usually grow back, but it may take several months.

Improving Subungual Hematoma and Seeking Medical Help

In addition to medications and procedures, several home remedies can help alleviate symptoms and promote healing of a subungual hematoma. These include:

1. Rest: Limiting movement and avoiding pressure on the affected finger or toe can reduce pain and prevent further injury.
2. Ice Application: Applying ice for 15-20 minutes at a time can reduce swelling and numb the pain.
3. Elevation: Keeping the affected limb elevated can reduce blood flow to the area, minimizing swelling and discomfort.
4. Compression: Gently wrapping the area with a bandage can provide support and reduce swelling.
5. Warm Soaks: After the initial swelling subsides, soaking the area in warm water can promote circulation and healing.
6. Aloe Vera: Applying aloe vera gel can soothe the skin and reduce inflammation.
7. Tea Tree Oil: Known for its antiseptic properties, tea tree oil can help prevent infection when applied to the affected area.
8. Vitamin E: Applying vitamin E oil can promote healing and improve the nail’s appearance as it grows back.
9. Turmeric: Turmeric has anti-inflammatory properties that can help reduce pain and swelling when applied topically or taken as a supplement.
10. Epsom Salt Soaks: Soaking the area in warm water with Epsom salts can reduce swelling and promote healing.

If symptoms persist or worsen, seek medical help. Telemedicine offers a convenient way to consult with a healthcare provider from home. Through a virtual visit, your doctor can assess your condition and recommend appropriate treatment, whether it be medications, drainage, or further intervention. Telemedicine provides quick and easy access to care, especially for minor injuries like subungual hematomas.

Living with Subungual Hematoma: Tips for Better Quality of Life

Living with a subungual hematoma can be uncomfortable, but there are steps you can take to improve your quality of life while you heal:

1. Keep the affected area clean and dry to prevent infection.
2. Wear protective footwear or gloves to avoid further injury to the nail.
3. Take pain relievers as needed to manage discomfort.
4. Follow your doctor’s care instructions, especially after procedures like drainage or nail avulsion.
5. Be patient—nails take time to heal, and it may take several months for a new nail to grow back fully.

By following these tips and seeking medical care when necessary, you can minimize discomfort and ensure a smooth recovery.

Conclusion

A subungual hematoma occurs when blood collects under the nail, usually due to trauma. While painful, most cases resolve with simple treatments like pain relievers, ice, and rest. In more severe cases, medical procedures such as drainage or nail avulsion may be necessary.

Early diagnosis and treatment are crucial to prevent complications and ensure a faster recovery. If you are experiencing symptoms of a subungual hematoma, our telemedicine practice can provide the care you need. Schedule a virtual consultation today to discuss your symptoms and receive personalized treatment recommendations.

James Kingsley

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