Introduction
Most young adults who have nail problems have problems with their big toe nails. It rarely happens to fingernails. There are three types of nail ingrowth: lateral ingrowth, distal ingrowth, and proximal ingrowth (retronychia). The most common type is distal-lateral ingrowth (onychocryptosis). All types of nail ingrowth cause the tissues around the nail to become inflamed and painful. Granulomas may also form.
Simple Explaination Of The Medical Term: Ingrown Toenail
What is an ingrown toenail?
An ingrown toenail happens when the side or corner of your toenail grows into the flesh around it. It usually affects the big toe.
What are the symptoms of an ingrown toenail?
The symptoms include pain, redness, and swelling where the nail has grown into the flesh.
Is there a test for an ingrown toenail?
No. Your doctor or nurse should be able to tell if you have it by learning about your symptoms and doing an exam.
Is there anything I can do on my own to feel better?
Yes. Some people feel better if they:
- Place a small piece of a cotton ball or some dental floss underneath the nail to take pressure off the toe.
- Soak the foot in warm, soapy water. Do this for 10 to 20 minutes, 2 to 3 times a day, for 1 to 2 weeks. You can also use 1 to 2 teaspoons of Epsom salts (available in drug stores) in the water instead of soap.
Should I see a doctor or nurse?
See your doctor or nurse if redness and swelling become worse and there is pus.
How is an ingrown toenail treated?
If the treatments you have tried on your own don’t help, your doctor might cut away part of your toenail. They will first inject a medicine to numb your toe. Afterwards, you will need to:
- Clean the area two to three times per day. Make a mixture of equal parts water and hydrogen peroxide and dab it on your toe with a cotton swab.
- Put antibiotic ointment on your toe. Examples include bacitracin and mupirocin (brand name: Bactroban).
Can an ingrown toenail be prevented?
You can reduce your chances of getting an ingrown toenail by:
- Wearing shoes that are not too tight around your toes
- Cutting your toenails straight across and not too short
Management of Ingrown Toenail
Ingrown toenails can be treated both without surgery (conservatively) and with surgery. Several small, randomized trials have shown that surgical treatments are better at keeping ingrown toenails from coming back than non-surgical treatments. But in most cases, the choice of treatment depends a lot on the stage of the disease when it is found, the expertise of the doctor, and what the patient wants. Some people with a mild to moderate ingrown toenail may prefer surgery because it is faster and more permanent than other treatments.
Conservative Treatment
Indications and goals of treatment
A conservative approach is indicated for mild to moderate ingrown nails that present with slight erythema and swelling of the nail fold and moderate pain to the touch. The goals of conservative treatment include reducing inflammation and pain, protecting the nail fold from the nail plate edge, and preventing relapse or progression to a severe stage.
General measures
Patients may soak the affected foot in warm, soapy water for 10 to 20 minutes twice daily, followed by the application of a high-potency topical corticosteroid ointment for two weeks. High-potency topical corticosteroids have been successfully utilized in early, mild retronychia.
For distal embedding, 50% urea ointment can be applied to the distal rim and massaged in a distal-plantar direction to reduce the hypertrophic hyponychium.
Techniques
Several conservative techniques aimed at protecting the lateral nail fold from the offending nail plate edge have been described:
Cotton nail cast (packing) – Packing is a simple method that involves removing the nail spicule with local anesthesia and lifting and separating the offending nail edge from the nearby soft tissue with a small piece of absorbent cotton or gauze that can be held in place with cyanoacrylate glue. The cast should be changed every week, even if the patient does it themselves, and should stay on until the free edge is reached. This is the author’s usual conservative way to treat mild to moderate ingrown toenails because it stops the pain right away and is easy and quick to do in the office.
Dental floss – In mild cases, a variant of the packing technique utilizes a piece of dental floss placed under the nail corner to separate it from the nail fold. This procedure does not require local anesthesia.
Taping – Taping can be used to pull the lateral nail fold away from the spicule. A piece of adhesive elastic tape is placed on the affected nail fold(s) and pulled in an oblique and proximal direction over the toe, avoiding constriction of the toe. An additional layer of tape can be used to increase stability. Patients should be instructed to replace and reposition the tape at home. Taping requires several weeks to produce improvement. The tape adhesiveness is often limited because of hyperhidrosis or oozing granulation tissue.
Gutter treatment – A piece of sterile plastic tube, such as a vinyl intravenous drip infusion tube, is cut lengthwise to open it. Under local anesthesia, the lateral nail margin is freed from the nail fold, and the gutter is slid over it. The gutter is fixed with cyanoacrylate glue and kept in place for six to eight weeks.
Nail bracing – Nail bracing uses various devices (hook, adhesive, or composite), depending on the accessibility of the nail folds (picture 14), to straighten the curvature of the nail.
Acrylic nail – For distal embedding, application of an acrylic nail to the distal end of the nail plate that compresses the hypertrophic hyponychium will help the distal nail to reach the tip of the digit. The acrylic nail is then removed by cutting the free edge.
Surgical Treatment
Indications and goals of treatment
When conservative treatments haven’t worked and the condition is severe, very painful, or keeps coming back, surgery may be needed. Surgical treatment aims to permanently reduce the width of the nail plate by destroying the lateral horn of the nail matrix or to shrink the soft tissues around the nail, depending on the type of surgery chosen.
Surgical techniques
Various techniques have been described for the definitive treatment of ingrown nails. In most cases, the choice depends on the clinician’s surgical skills and preference. However, most authorities consider partial nail avulsion with chemical phenol matricectomy as the treatment of choice, based on its efficacy, low rate of complications, and low recurrence rate.
A 2021 Cochrane review found that the addition of chemical nail matrix ablation with phenol to partial nail avulsion resulted in a significant reduction in the risk of recurrence compared with partial nail avulsion alone.
Partial nail avulsion with chemical matricectomy – This technique is the author’s treatment of choice for severe distal-lateral ingrown toenail.
After local anesthesia with digital block and mechanical avulsion of the lateral portion of the nail plate (3 to 5 mm wide, on average, depending on nail size and ingrown severity), the author utilizes a cotton tip to apply phenol at 88% concentration to the lateral matrix horn for two to three minutes. As blood neutralizes phenol, it is important to apply a tourniquet to the digit to avoid bleeding. Phenol has antiseptic, anesthetic, and protein coagulant properties, which reduce postoperative pain and risk of infections.
Electrocautery and lasers are effective and safe alternatives for the destruction of the matrix horns. However, they cause more inflammation and postoperative pain than phenol. The clinician’s skills are important to ensure complete destruction of the horn, otherwise a nail spicule will grow in the proximal nail fold after surgery.
Simple total or partial nail avulsion – Simple total or partial nail avulsion without chemical or surgical ablation of the lateral matrix is associated with high recurrence rates and is not recommended in distal-lateral embedding.
In contrast, simple avulsion of all superimposed nails is the treatment of choice for retronychia. It allows for rapid resolution of pain and provides definitive treatment.