(P10) Green Nail Syndrome

Introduction: Green nail syndrome, also known as chloronychia, is an infectious disorder characterized by green discoloration of the nail. It is a common complication of paronychia, onycholysis, and onychotillomania. It is common in patients whose hands are constantly exposed to water, soaps, and moist environments or are subject to mechanical trauma, especially in older adults. This syndrome can be a mimicker of melanoma. Paronychia is common in skilled nursing facility residents, so it is beneficial to evaluate for green nail syndrome.

Case Description: An 84-year-old female was seen in the long-term care setting for evaluation of a 2-month history of a darkish-green discoloration in her right middle finger. There was a concern that this could be a presentation for melanoma. Within three weeks of her initial evaluation, she developed similar lesions in multiple fingers’ nail beds. The resident could not be evaluated by dermatology in person due to transportation challenges. A curbside with dermatology was completed, using photos through the electronic medical record, and the resident was treated with acetic acid soaks and clobetasol 0.05% ointment twice a day for four weeks. Her symptoms cleared up within two weeks without recurrence.

Discussion: : Pseudomonas aeruginosa is the most common pathogen causing bacterial nail infections, producing a classic blue-green pigment. The green color is caused by the fluorescent siderophore pyoverdin and Pyocyanin that attaches to the nail plate. Clinical examination findings and nail discoloration involving one or more nails are consistent with the diagnosis. Dermoscopic results include a greenish discoloration with a fading border. Topical therapy is typically the first-line treatment, including topical antibiotics and antiseptic soaks. Systemic antibiotics may be needed in patients who do not respond to topical therapy. The treatment results in normalizing the nail color. Differential diagnosis includes melanoma, subungual hematomas, and exposure to green dye, paint, or lacquers. Prevention of recurrence includes avoiding excessive moisture and protection. Recognizing a treatable condition in the long-term setting is crucial. As a long-term care provider, the ability to care for patients without needing to refer them to a specialist will provide cost-effective, efficient, and comprehensive care.