The Green Nail Syndrome (“Chloronychia”) in Healthcare Workers: Challenges and Strategies

Dear Editor,

A Pseudomonas aeruginosa nail infection poses a dual threat to healthcare providers—serving as both an occupational skin disease and a potential source of nosocomial infections in hospital settings.[1] The present case report focuses on a pediatric emergency ward nursing staff member presenting with a unique greenish-black discoloration of the nail plate and mild inflammation of the proximal nail fold on one finger, persisting for two months. Additionally, there was an asymptomatic longitudinal elevated ridge culminating in a focus on distal onycholysis [Figures 1 and 2]. Following clinical evaluation and culture testing, a diagnosis of “chloronychia” caused by Pseudomonas aeruginosa was established. A KOH (Potassium hydroxide) mount was also performed, which was negative, to exclude any concurrent onychomycosis. She was advised to apply topical tobramycin eye drops twice daily for 3 months, along with counseling on stringent hand hygiene practices, and temporary reassignment to the outpatient section. The authors planned to address the elevated ridge after resolving the nail infection, attributing it to a benign nail matrix tumor. Unfortunately, follow-up was lost when her tenure ended. The case sparked a broader discussion on hospital practices, emphasizing the need for preventive measures and protocols to ensure patient safety within the healthcare ecosystem. The present report aims to delve into these pertinent issues.

Figure 1.

Greenish-black discoloration and mild inflammation of proximal nail fold in an otherwise healthy healthcare worker. A longitudinal elevated ridge runs across the midline, ending distally in onycholysis

Figure 2.

Focal separation of the distal free edge of the nail plate from the nail bed (onycholysis) aligning with the midline ridge may serve as a potential point for pathogen entry and persistence

Amid the emphasis on frequent hand-washing and glove use among medical personnel, it is important to acknowledge that these practices create a damp microenvironment conducive to P. aeruginosa colonization.[1] This raises the risk of occupational skin diseases like chloronychia—a nail infection identified by a greenish-black discoloration of the nail plate, often accompanied by onycholysis and/or paronychia. Also known as the “Goldman Fox” or “green nail” syndrome, this manifestation is more likely in individuals with predisposing factors like pre-existing nail pathologies and recurrent exposure to cleansing agents.[2]

Recognizing this onychopathy among healthcare workers is imperative, as the therapeutic implications significantly differ from community-acquired cases. Contaminated hands and equipment can trigger nosocomial infections, particularly among immunocompromised patients, or those in intensive care, surgical operative, postoperative, and wound care units.[1,3] While a Pseudomonas nail infection is typically superficial and localized with a favorable prognosis, the outlook can become grave when the organism gets acquired by hospitalized patients as opportunistic infections like pneumonia, skin and soft tissue infections (ecthyma gangrenosum, otitis externa, necrotizing gangrene, etc.), and rarely, sepsis.[2] Pseudomonas aeruginosa, accounting for 7.1%–7.3% of nosocomial infections, significantly impacts medical systems, especially in healthcare-associated and ventilator-associated pneumonia cases, where outcomes are worse compared to other organisms.[4] A “green nail” case in an intensive care unit staff resulted in P. aeruginosa infection in multiple patients.[3] Amid the COVID pandemic, a study revealed that 80% of 61 hospitalized patients with acute respiratory infections tested positive for P. aeruginosa in bronchial aspirates, emphasizing the need to address this issue in healthcare facilities.[1]

When confronted with a “green nail” presentation among medical staff, seeking urgent dermatological opinion is necessary. While the clinical appearance is distinctive, dermoscopy may aid in doubtful cases, and culture/sensitivity study of onycholytic nail clippings is confirmatory.[2] The treatment approach focuses on averting predisposing factors, meticulous clipping of the detached (onycholytic) nail plate, and subsequent twice-daily application of topical antiseptics along the affected nail bed for 2-4 months. The latter include 2% sodium hypochlorite solution (household chlorine bleach, diluted 1:4 with water), aminoglycosides like tobramycin eye drops, or vinegar/acetic acid compresses.[2] Additionally, reports document the use of topical neosporin, silver sulfadiazine, gentamicin, bacitracin, polymyxin B, and nadifloxacin.[2,5,6] In cases that are geriatric, treatment-resistant, or associated with pain, ciprofloxacin may be administered at 500 mg twice daily for 3 weeks.[5,6] Any co-existing nail pathology must be addressed.[2] In this case, the authors attributed the focus of distal onycholysis, aligned with the midline longitudinal ridge, to a possible benign nail bed/matrix tumor like an onychopapilloma. Although unconfirmed, it is important to recognize that such concurrent onychopathies with onycholysis may serve as points for pathogen entry and persistence.[7]

An extensive literature review informs a compendium of evidence-based recommendations and preventive strategies, designed for seamless integration into standard healthcare facility protocols [Table 1]. These efforts systematically address hidden infection reservoirs like chloronychia in the healthcare ecosystem, reducing the risk of nosocomial transmission.[2,8,9,10,11,12,13]

Table 1.

Evidence-based recommendations for healthcare workers (HCWs) and facilities to prevent Pseudomonas transmission

Modification	Evidence	Recommendation for healthcare settings
Nail length	Longer nails harbor more microbes, and pose risks to glove integrity.[9,10]	Maintain short nails (2 mm beyond fingertip), trim regularly.[9,10]
Nail polish	Painted nails conceal changes; chipped polish acts as a microbial reservoir.[9,10,13]	Discourage painted nails in healthcare workers (HCWs).[2]
Artificial nails	Increase microbial infiltration, hinder effective hand cleaning.[6,9,10,13]	Avoid artificial, gel nails, and nail art in healthcare settings.[6,9,10]
Cleansing and grooming	Unique nail anatomy makes it infection-prone. Cuticles serve as a protective barrier.[9]	Gentle cleansing of the undersurface of nails during handwash. Avoid nail-biting or ripping of hangnails; use a sanitized nail cutter instead. Avoid cutting cuticles or the use of shared nail equipment as in commercial salons.[9,10]
Periungual skin barrier	Repetitive handwashing and sanitizer use may cause dryness, hangnails, and cuticle disruption.[9]	Prefer alcohol-based sanitizers with humectants, apply moisturizer at night, and seek dermatological advice for hand dermatitis/paronychia.[9]
Co-existing pathologies	Onychopathies disrupt protective nail barriers, and harbor pathogens.[9]	Seek dermatological opinion for concomitant onychopathies including nail tic disorders.[9]
Hand jewellery	Hinders proper handwashing techniques; linked to increased bacterial counts.[10]	Avoid rings and bracelets, especially in high-risk settings. Establish policies on hand jewelry, prioritizing transmission risks over cultural preferences.[9,10]
Hand washing	Despite proven efficacy, HCWs exhibit low compliance, especially in emergencies.[11]	Critical compliance with the ”20-second” handwash technique. Use alcohol-based sanitizers if soap is unavailable. Dry hands promptly.[11,13]
Glove hygiene	Glove use may instill a false sense of security, reducing hand hygiene compliance. Frequent glove use causes microtears, compromising integrity. HCWs often overlook changing gloves between patients.[11,13]	Enforce hand-washing after glove removal and compliance checks. Remove gloves after tending to a single patient, especially when transitioning between different body sites (e.g., non-intact skin, mucous membrane, invasive medical device) within a patient.[13]
Environment & surface	Hospital surfaces harbor reservoirs of infective organisms, including P. aeruginosa.[4,11]	Routinely deep clean hospital areas according to cleaning levels and device categorization; implement active surveillance cultures.[11,13]
Administrative changes	An HCW with a ”green nail” is a potential carrier. Proactive precautions are necessary for high-risk healthcare roles.[2]	Pre-emptive isolation of affected HCWs from high-risk patients and scenarios; proactive use of sterile gloves; consider temporary duty re-allocation.[2,13]
Staff cohorting	An established component of the infection control strategy.[13]	For an infected HCW, cohort by sharing shifts and break rooms. Ensure HCWs stay within a single cohort per shift, exclusively caring for assigned patients without transitioning.[13]
Education and screening	Early diagnosis and treatment are crucial to mitigate infection transmission to and from HCWs.[11]	Establish ongoing awareness programs, education on P. aeruginosa infections, nail self-check practices, examination of colleagues of affected HCWs, and timely dermatological referral.[2]

In conclusion, this report underscores concerns regarding “occupational onychopathy” among medical personnel in high-risk environments, highlighting the propensity for subungual P. aeruginosa colonization and the potential risk of nosocomial infections.[1,2,3] Despite being clinically identifiable, this seemingly innocuous condition may be inadvertently overlooked. This summary offers valuable insights and proactive strategies for healthcare facilities to reduce transmission risks for both providers and patients.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.