Green Discoloration Under a Lifted Acrylic: Fill or Refer?
At 4:15 p.m. on a Friday, a 34-year-old client arrives for a fill on an acrylic set applied 18 days ago. She is getting engagement photographs in two days and asks you to “file off the ugly part and cover it.” On the right thumbnail you see a dark olive-green patch near the lateral wall, about 6 mm across, with the acrylic lifted along the side. There is a faint musty odor but no pain, pus, or fever. The nail folds are not swollen. She has been swimming twice weekly and admits she has been picking at the lifted edge. During the previous fill you used a metal cuticle nipper, a 180-grit file, a buffer, and an e-file bit on this nail. She does not want to see a doctor because she has no insurance and insists the green is “just a bruise from the pool.”
1. Is this a situation for a fill, a removal, or a referral? Explain the reasoning and state what you would say to the client.
Read the worked answer
The green-black discoloration under a lifted enhancement, especially with moisture exposure and a broken seal, is most consistent with bacterial colonization by Pseudomonas (green nail syndrome). It is not a bruise; a bruise would not look olive-green after 18 days and would not track under lifted product. I cannot diagnose, so I would describe it as “suspicious for bacterial infection” and decline the fill. Sealing fresh acrylic over the area traps moisture and bacteria, can worsen the infection, and may spread contamination to files, bits, and surfaces.
The safe plan is to stop the service, explain that I cannot cover an area that looks infected, and refer her to a physician or nurse practitioner, especially with photographs in two days. I would not aggressively remove the enhancement in the salon if the tissue is inflamed; if removal is requested, I would do only gentle, atraumatic removal with client consent and never dig at the sidewall. I would advise keeping the area clean and dry, not covering it with polish, and seeking care if pain, swelling, pus, or fever develops. Her insurance concern is real, but cost does not change the infection-control risk.
2. What must happen to the implements and surfaces that contacted the nail before you recognized the problem?
Read the worked answer
Because the bit and nipper touched the lifted area before I stopped, they are contaminated. I would put on fresh gloves, avoid touching clean surfaces, and remove the bit from the handpiece. The single-use 180-grit file and buffer go into the trash-never into a drawer for reuse. The metal nipper and e-file bit are cleaned first: scrub with soap and water and a brush to remove visible debris, rinse, and dry. Then immerse them in an EPA-registered hospital-grade disinfectant labeled as tuberculocidal, using the full contact time on the label; a quick spray or wipe is not enough for items that contacted broken skin. The handpiece is cleaned per its manufacturer’s instructions, and the work surface barrier is replaced. I wash my hands, change gloves, and disinfect the table. I do not put the implements back into service until the contact time is complete. If an item cannot be cleaned or disinfected, it is discarded.
3. Write the documentation and follow-up you would use, avoiding a diagnosis.
Read the worked answer
The record should be factual, not diagnostic. I would write the date and time, “Right thumbnail: 6 mm olive-green discoloration at lateral wall; acrylic lifted; faint odor; no pain, pus, or fever reported; nail folds not swollen.” I would note that the client requested a fill, that I declined and explained the reason, and that I referred her to a physician or nurse practitioner. I would list the implements used and the disinfection steps, including the disinfectant name, dilution, and contact time. I would not write “fungus” or “Pseudomonas infection” as a diagnosis; instead, “suspicious for bacterial infection-medical evaluation recommended.” I would give written aftercare: keep dry, do not cover with polish or acrylic, do not pick, and seek care for spreading redness, pain, pus, or fever. I would ask her to sign that she received the referral and aftercare, and I would schedule a follow-up call after the wedding. If she returns with a physician’s clearance, I would reassess before any service.