Green-Black Patch Under a Lifted Enhancement
A repeat client, 34, comes in for a fill three weeks after her last appointment. On the right index finger, under the free edge of the acrylic, there is a dark green-black patch on the nail plate with a musty smell. The plate has separated from the nail bed about 2 mm at the free edge, and the enhancement is slightly lifted along that sidewall. The surrounding skin is not swollen, red, or painful, and she has no fever. She says the color 'just showed up' about a week ago and that she has worn enhancements continuously for eight months. The other nine nails look normal. She insists you 'just file it out and cover it' because she has a wedding on Saturday.
1. What is the most likely explanation for the green-black discoloration, and what findings would make you consider something else? Name at least two alternatives.
Read the worked answer
Most likely: bacterial colonization of the pocket under the lifted edge - Pseudomonas aeruginosa, the classic 'greenies.'
- Green-black pigment confined to the plate under a lifted edge
- Musty odor - points to bacteria, not blood or pigment
- Onycholysis has created a warm, dark, wet, oxygen-poor pocket
- Eight months of continuous wear with no break sets up repeated micro-lifting
- No redness, swelling, or pain argues against a spreading soft-tissue infection right now
Alternatives that would change the picture:
- Subungual hematoma - remembered trauma, dark red-brown-purple, no odor, spot migrates out with plate growth
- Melanonychia / subungual melanoma - a pigmented band running cuticle to free edge on a single digit, pigment spilling onto the proximal fold (Hutchinson's sign), no odor; refer
- Onychomycosis - yellow-white, thickened, crumbly plate, no green pigment
- Staining - dye, nicotine, or a dark base coat
I describe and refer. I do not diagnose.
2. Do you perform the service she is asking for? Walk through your decision and what you actually do in this appointment.
Read the worked answer
No - I do not file it out and cover it. Sealing over that pocket keeps it dark, wet, and oxygen-poor, so the colony expands and the separation spreads. The abrasive dust also contaminates files, brushes, and the table.
- Stop and explain; get consent to remove the enhancement on that nail only.
- Remove product without cutting into the discolored plate or digging the pocket back - no credo blade, no nipper work in the fold.
- Cleanse and dry; leave the plate bare. No polish, no primer, no enhancement over it.
- Refer to a physician or dermatologist - mandatory if there is discharge, pain, spreading redness, or a new dark band.
- Consumables that touched the area (file, buffer, wipe) go in the trash; reusable implements are scrubbed, then fully immersed in an EPA-registered hospital-grade disinfectant at label dilution and contact time.
- Fresh implements for the other nine nails, and keep the bare nail physically separated from the rest of the service.
- Offer to finish the other nine nails so she is presentable for Saturday.
If she refuses removal, I still do not seal over it. I decline that nail and document the refusal.
3. What do you say to the client, and what goes in her record?
Read the worked answer
Say it plainly, without a diagnosis: 'There is a dark green patch under the lifted edge of this nail and it has an odor. That usually means moisture and bacteria are trapped between the product and the nail. Covering it traps it further and can make the nail separate more. I can take the product off this nail and leave it bare, and you should have a doctor look at it.'
- Do not say 'you have a fungus' and do not prescribe or recommend a cure beyond keeping it dry
- Acknowledge the wedding; give her the option of finishing the other nine nails
Record: date; nail involved; size, location, color, and odor of the patch; degree of lifting and separation; absence of redness, swelling, and pain; product removed; that no enhancement was reapplied; that a physician referral was advised; that she was told to return once it clears or with a note; and her response, with signature if she declined. Photos with consent help. That note protects both of us.