Ingrown nail
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Synonyms and keywords: Ingrown toenails; ingrowing nails; ingrown nails; unguis incarnatus
Natural History, Complications and Prognosis
Complications
Many complications of an ingrown nail exist, especially if the nail is left untreated. An untreated ingrown toenail will cause a person to walk with a limp, which over a long period of time may cause further pain and injury to the foot, leg and back owing to improper distribution of weight. Other non-direct effects of seriously ingrown nails include lack of exercise, constant and unrelenting pain and pressure, the spread of infection, loss of appetite, inability to move around, and psychological effects (like anxiety, stress and feelings of despair). Amputation of the toe, foot or leg may be the final outcome if the infection is left untreated long enough for gangrene to set in. An untreated infection may also lead to a condition known as osteomyelitis, where the infection spreads to the bone of the infected digit. Once in the bone, the infection is more difficult to remove and may require the intravenous treatment of antibiotics. One should always consult a doctor when infection is present.
Diagnosis
Symptoms
Pain along the margins of the nail (caused by hypergranulation), worsening of pain when wearing shoes or other tight articles of clothing, and sensitivity to pressure of any kind, even that of light bedding may be present. Bumping of an affected toe with objects can produce sharp, even excruciating, pain as the tissue is punctured further by the ingrown nail. By the very nature of the condition, ingrown nails become easily infected unless special care is taken to treat the condition early on and keep the area as clean as possible. Signs of infection include redness and swelling of the area around the nail and drainage of pus and watery discharge tinged with blood. The main symptom is swelling at the base of the nail on whichever side (if not both sides) the ingrowing nail is forming.
Treatment
Treatment of ingrown nails ranges from soaking the afflicted area to surgery. The appropriate method is dictated by the severity of the condition. In nearly all cases, drainage of blood or watery discharge should mean a trip to the doctor, usually a podiatrist, a specialist trained explicitly to treat these conditions. Most practitioners agree that trying to outwait the condition is nearly always fruitless, as well as agonizing.
Pharmacotherapy
Acute Pharmacotherapies
When the case of an ingrown nail is not severe, there are treatments that can be completed at home without a doctor's help. In mild cases doctors recommend daily soaking of the afflicted digit in a mixture of warm water and Epsom salts and applying an over-the-counter antiseptic. This might allow the nail to grow out so it may be trimmed properly and the flesh to heal. A simple yet extremely painful procedure for mild ingrowth (i.e., where infection is absent) requires small scissors to trim the nail completely along the nail margin down to the lateral base. This hopefully allows the embedded piece of nail to be pushed back and out from the toe tissue. It should be noted that infection may be somewhat difficult to prevent in cleaning and treating ingrown nails owing to the warm, dark, and damp environment in shoes. Peroxide is immediately effective to help clean minor infections but iodine is more effective in the long term as it continues to prevent bacterial growth even after it is dry. Iodine should not be used on deep wounds. In such cases a physician or podiatrist should be consulted. Also, bandages can help keep out bacteria but one should never apply any of the new types of spray-on bandages to ingrown nails that show any discharge - preventing drainage will likely cause intense swelling and pain.
It is also advisable to walk around barefoot so that air has a chance to circulate. Infections often become more painful when they are not exposed to air because bacteria grows more quickly in warmer conditions such as when the foot is impacted tightly in a shoe.
These home remedies are, in serious cases, ineffective: when the flesh is far too swollen and infected, it will not allow for these procedures to work. Thus, these more severe cases, such as when the area around the nail becomes infected or the nail will not grow back properly, must be treated by a professional and the patient should avoid repeated attempts at this type of 'bathroom surgery.'
Chronic Pharmacotherapies
For long term treatment, Iodine would be the more effective treatment. Iodine continues to prevent bacterial growth even after it has dried.
Surgery and Device Based Therapy [1]
Phenolisation[2] [3] is a method that can be employed to help heal an ingrown nail. Following injection of a local anesthetic at the base of the toenail and perhaps application of a tourniquet, the surgeon will remove (ablate) the edge of the nail growing into the flesh. He will then destroy the matrix area with phenol to permanently and selectively ablate the matrix that is manufacturing the ingrown portion of the nail (i.e., the nail margin). This is known as a partial matrixectomy, phenolisation, phenol avulsion or partial nail avulsion with matrix phenolisation. Also, any infection is surgically drained. After this date, other suggestions on aftercare will be made, such as salt water bathing of the digit in question. The point of the procedure is that the nail does not grow back where the matrix has been cauterized and so the chances of further ingrowth are very low. The nail is slightly (usually one millimeter or so) narrower than prior to the procedure and is barely noticeable one year later. The surgery is advantageous because it can be performed in the doctor's office under local anesthesia with minimal pain following the intervention. Also, there is no visible scar on the surgery site and a nominal chance of recurrence. The procedure will fail in about 2 to 3 times out of a hundred.
A wedge resection is a partial removal of the nail or an offending piece of nail. It is more complex than a complete nail avulsion (removal). Here, the digit is first injected with a common local anesthetic. When the area is numb, the physician will perform an onychotomy in which the nail along the edge that is growing into the skin is cut away (ablated) and the offending piece of nail is pulled out. Any infection is surgically drained. This process is referred to as a wedge resection or simple surgical ablation and is non-permanent (i.e., the nail will re-grow from the matrix). The entire procedure may be performed in a physician's office and takes approximately thirty to forty-five minutes depending on the extent of the problem.
It should be noted that some physicians will not perform a complete nail avulsion (removal) under any but the most extreme circumstances. In most cases, these physicians will remove both sides of a toenail (even if one side is not currently ingrown) and coat the nail matrix on both of those sides with a chemical or acid (usually phenol) to prevent re-growth. This leaves the majority of the nail intact, but ensures that the problem of ingrowth will not re-occur.
There are some disadvantages in performing a wedge resection. If the nail matrix is not coated with the applicable chemical or acid (phenol) and is allowed to re-grow, this method is prone to failure. Also, the underlying condition can still become symptomatic as the nail grows out over the course of up to a year: the nail matrix might be manufacturing a nail that is simply too curved, thick, wide or otherwise irregular to allow for normal growth. Furthermore, the flesh can be injured very easily by concussion, tight socks, quick twisting motions while walking or just the fact the nail is growing incorrectly (likely too wide). This hypersensitivity to continued injury can mean chronic ingrowth; the solution is nearly always edge avulsion by the highly successful phenolisation.
CO2 laser surgery is another surgical procedure that can be used to treat an ingrown nail. Following injection of a local anesthetic at the basis of the toe and perhaps application of a small tourniquet, the surgeon will remove (ablate) the edge of the nail growing into the flesh and cauterize the matrix area by laser photocoagulation. This too is known as a partial matrixectomy or partial nail avulsion. The point of the procedure is that the nail does NOT grow back where the matrix has been cauterized and so the chances of further ingrowth are very low. The nail is slightly (usually one millimeter or so) narrower than prior to the procedure.
There are a few disadvantages to CO2 laser surgery in that sutures are usually necessary, and there is post-operative pain due to the wound and scar.
A nail avulsion (removal) is an extreme option for fixing an ingrown nail. While in some similar cases patients may wish to have the offending nail completely temporarily removed (avulsion), this procedure is not recommended by nail experts because the postoperative period is long and painful. Furthermore, complete removal of a whole nail does not always prevent recurrences. In case of recurrence in spite of complete removal, and if the patient never feels any pain before inflammation occurs, the condition is more likely to be onychia which is often confused for an ingrown or ingrowing nail (onychocryptosis).
Complete removal of a whole nail is a simple procedure. Here, anesthetic is injected, the nail is removed quickly and painlessly and the patient can leave immediately. The entire procedure can be performed in around 10 minutes and is much less complex than a wedge resection. The nail will grow back. However, in most cases it will cause further problems because it can become ingrown very easily as the nail grows outward. It can become easily injured by concussion and in some cases grows back too thick, too wide or deformed. This procedure can thus result in chronic ingrown nails and is therefore considered a generally unsuccessful solution, especially considering the pain involved.
Accordingly, in some cases as determined by a doctor, the nail matrix is coated with a chemical (usually phenol) so none of the nail will ever grow back. This is known as a permanent or full nail avulsion, or full matrixectomy, phenolisation, or full phenol avulsion. As can be seen in the images below, the nail-less toe looks much like a normal toe and fake nails or nail varnish can still be applied to the area.
Post-Operative Management
For a Wedge resection, the patient is allowed to go home immediately and the recovery time is anywhere from a few days to a week barring any complications such as infection. As a followup, a physician may prescribe an oral or topical antibiotic or a special soak to be used for approximately a week after the surgery.
Primary Prevention [4]
The most common place for ingrown nails is in the big toe but ingrowth can occur on any nail. Ingrown nails can be avoided by cutting nails straight across; nails should not be cut along a curve, nor should they be cut too short. Footwear which is too small, either in size or width, or those with too shallow a 'toe box' will exacerbate any underlying problem with a toenail.
Ingrown toe nails can be caused by injury, commonly concussion where the flesh is pressed against the nail causing a small cut that swells. Also, injury to the nail can cause it to grow abnormally, making it thicker or wider than normal or even bulged or crooked. Stubbing the toenail, dropping things on the toe and 'going through the end of your shoes' in sports are common injuries to the digits. Injuries to the toes can be prevented by wearing shoes most of the time, especially when working or playing.
One myth is that a V should be cut in the end of the ingrown nail; this myth is untrue. The reasoning of the myth is that if one cuts a V in the nail, the edge of the nail will grow together as the nail grows out. This does not happen - the shape of the nail is determined by the growing area at the base of the toe and not by the end of the nail.
References
- ↑ Rounding C, Bloomfield S (2005). "Surgical treatments for ingrowing toenails". Cochrane Database of Systematic Reviews (Online) (2): CD001541. doi:10.1002/14651858.CD001541.pub2. PMID 15846620. Retrieved 2012-08-06.
- ↑ Kominsky SJ, Daniels MD (2000). "A modified approach to the phenol and alcohol chemical partial matrixectomy". Journal of the American Podiatric Medical Association. 90 (4): 208–10. PMID 10800276. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Boberg JS, Frederiksen MS, Harton FM (2002). "Scientific analysis of phenol nail surgery". Journal of the American Podiatric Medical Association. 92 (10): 575–9. PMID 12438504.
|access-date=requires|url=(help) - ↑ Aksakal AB, Ozsoy E, Gürer M (2003). "Silicone gel sheeting for the management and prevention of onychocryptosis". [[Dermatologic Surgery : Official Publication for American Society for Dermatologic Surgery [Et Al.]]]. 29 (3): 261–4. PMID 12614420. Retrieved 2012-08-06. Unknown parameter
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