Green Nail Syndrome
Green nail syndrome is found in a disorder caused by the growth of the bacterium Pseudomonas aeruginosa under the nail. It usually occurs when the hands are exposed to a moist environment on a long-term basis. It is usually found in association with chronic non-tender paronychia, manifested as thickening of the proximal nail fold without pain or tenderness. In addition, onycholysis of the distal and lateral parts of the nail plate is observed.
Green discoloration of the nail is the key clinical sign.
The green coloration is not removed by scrubbing the nails.
Often associated with Pseudomonas aeruginosa infection of the nail plate and nail bed.
In severe cases, the nail may become thickened, brittle, or partially detached.
ndividuals with frequent exposure to water or moist environments, such as:
Dishwashers, cleaners, and healthcare workers
Swimmers and people who frequently wear occlusive footwear
Those with damaged or separated nails (onycholysis), which create a space for bacterial growth.
People who use chemical solutions or detergents frequently without adequate hand protection.
Individuals with preexisting nail disorders or weakened immunity.
General Management
Diagnosis is clinical based on nail color and history of moisture exposure.
In severe cases, partial or complete surgical removal of the affected nail may be required.
Prevent recurrence by keeping nails dry and using cotton-lined latex gloves during wet work.
2. Topical Antiseptics (First-line for mild cases)
Used as soaks to reduce bacterial load.
Common agents:
Chlorhexidine
2% sodium hypochlorite solution
1% acetic acid
Octenidine dihydrochloride
Adverse effects: local irritation, maceration from excess moisture.
3. Topical Antibiotics
Applied for several months; penetration through nail may be limited.
Examples:
Silver sulfadiazine
Tobramycin
Polymyxin B
Bacitracin
Nadifloxacin
Ciprofloxacin
4. Oral/Intravenous Antibiotics (For severe or resistant infections)
Quinolones: ofloxacin, ciprofloxacin, levofloxacin
Aminoglycosides: gentamicin, amikacin, tobramycin
Cephalosporins: ceftazidime, cefepime, cefoperazone
Carbapenems: imipenem, meropenem
Penicillins (anti-Pseudomonas): piperacillin, ticarcillin
5. Supportive Measures
Keep the area dry and clean.
Avoid nail trauma and prolonged water exposure.
Research continues on improving topical drug penetration (e.g., chemical or mechanical methods).
You should see a healthcare provider or dermatologist if:
The green discoloration spreads or worsens despite home care.
The nail becomes painful, swollen, or produces pus.
There are multiple nails affected.
You have underlying health conditions (e.g., diabetes, immune suppression).
You’re unsure of the cause — some fungal or mixed infections can mimic green nail syndrome.
There’s no improvement after 2–3 weeks of antiseptic or topical treatment.
The most common risk factor is chronic paronychia, or chronic infection of the lateral nail folds. This is often associated with prolonged exposure to moisture and dampness.
Hands which are exposed to chemicals and detergents or soaps for a long time every day are at risk for maceration, which predisposes to this infection. Thus it has been found to have an increased prevalence among occupations such as homemakers, bakers, barbers, and those who are engaged in medical tasks.
Other risk factors include:
- Onycholysis: separation of the nail from its underlying nail bed, which produces a warm moist place for bacterial growth
- Onychotillomania: a psychological condition characterized by constant picking at the nails
- Small injuries to the skin around the nails
- Associated nail disorders, such as psoriasis
Under these conditions, the organism proliferates and produces infection. On the other hand, keeping the hand dry prevents Pseudomonas colonization.
Pseudomonas aeruginosa is a Gram-negative organism which is responsible for a wide range of illnesses, ranging in severity from local skin infections to widespread fatal infection.It is often found in renal infections, lung infections, and urinary tract infections, as well as systemic infections.
It may enter the body through minor traumas, or foreign bodies under the nail. It characteristically infects the hair follicles, the webs between the toes and the nails.
References
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4135110/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4298286/
http://www.nejm.org/doi/full/10.1056/NEJMicm0706497
https://www.karger.com/Article/FullText/365863
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