A 29 y/o female patient presents with green discoloration of several of her fingernails. She made a manicure and artificial acrylic nails placed about 6 weeks ago. She noticed the discoloration when one of the artificial nails fell off inadvertently. She is married with 2 kids. Her medical history is unremarkable and she is on no current meds. She states no systemic symptoms. Her smoking and alcohol history is negative.

What's your diagnosis(es) and possible treatment plan(s)?

Idea and info in part from "Consultant" 2002;42 :749-50.

I think most people would try to assess for a microbial (bacterial or fungal) infection. Fungal cultures were negative. Pseudomonas aeruginosa was diagnosed on culture. Treatment was 15 minute alcohol soaks 2-3 times a day with frequent nail clippings. Discoloration and infection resolved in three weeks.

Pseudomonas and Candida are the most common causes of green nails. Other things in the differential may include dyes, chemicals, paints, etc, Aspergillus infections, subungual hematomas, and melanoma.

Pseudomonas requires water or moisture to live. Usually the dryness of the stratum corneum prevents growth of this bacteria. Trauma to the nails during the false nail application process may also be a contributing factor to infection. The acrylic nails applied increased hydration of the nail beds. Patients with underlying medical conditions, esp diabetes and other immunocompromised states, are at greater risk.

Other treatments may include: topical bacitracin, polymyxin, acetic acid in 50% alcohol, sulfacetamide 15% in 70% ethanol, 2-3 times a day soaks in alcohol or bleach diluter 1:4. Systemic antibiotics may be used but probably best held to second line therapy, unless signs and symptoms of systemic infection are apparent. Ciprofloxacin 500-750mg po BID for 4 weeks has been used. Just as important as the pharmacological treatment(s), is removal of the predisposing factors, if possible (excessive hydration, trauma).

Reference

Davisson L, Clark K. Green nail syndrome. Consultant. 2002;42:7449-50.