Treatment of the Ingrown Toenail
The ingrown toenail (onychocryptosis) is a
condition commonly encountered in primary care. The principal
problem usually involves the erosion or puncture of skin on the lateral border
of the great toe. The disorder can be stratified into three stages of
severity. Stage I is defined as erythema, swelling and
tenderness along the lateral nail edge. Increasing tenderness, and a
bulging of the lateral nail fold over the nail plate is characteristic of Stage
II. This stage also usually involves infection and abscess, and
can be quite painful. As granulation and subsequently
epithelial tissue covers the nail fold and of the lateral nail plate in Stage
III, drainage of the abscess is restricted. Stage
III will often become a chronic condition in which the presence of pain,
erythema, and infection waxes and wanes every few weeks.
Ingrown toenails are rarely described in cultures where shoes are not worn, and the relationship between shoes and this disorder are well established, as Joseph G. Richardson described in 1905:
The feet are subject to many diseases, but
the most common ones … ingrowing nails … are due to neglect of a few simple
rules which nearly all adults know. Fashion decrees that certain
shapes must be worn and the poor foot, willing to toil and bear, is pressed and
pulled out of shape by misshaped shoes. [1]
Prevention of the problem should be the physician’s first course of
action. The modern version of Dr. Richardson’s “few simple rules” is
summarized here:
Treatment
Several strategies are successfully
employed for treatment of ingrown toenails without surgical
intervention. The rationale for all of these methods is to separate
the nail from the lateral nail groove, allowing injured tissue to heal, while
encouraging the nail to grow normally.
The most common procedure, often attempted
by patients before presenting to the physician, involves the placement of a
cotton pledget into the lateral nailbed, and (if possible) under the offending
nail edge. Combined with good nail care, proper trimming, and
minimized pressure from shoes, this method is often effective for stage I and
Stage II nails.
For advanced stage II and Stage III, the
flexible tube procedure [2], performed under local anesthesia, involves
advancing a 2mm lengthwise-incised flexible plastic tube over the lateral nail
edge. The tube is fastened with wound closure strips (eg
Steri-Strip™ 3M corp, dkfkdj), and the toe is then washed daily with a cleaning
solution until the nail plate grows out normally, and erythema subsides.
An alternative to plastic tubing is a
procedure described by Lazar [3] in which the toe is soaked and cleaned, then
treated with EMLA cream. When adequate anesthesia is achieved, the
nail fold is cleaned thoroughly, debrided, and the granulation tissue is
cauterized with silver nitrate. A wound closure strip is then
introduced diagonally under distal corner of the nail, advanced proximally, and
left in place. (See figure X) The following day, the toe is soaked
once again, and a new wound closure strip carefully inserted. The
patient then repeats this process daily until the toe is healed (average 5
weeks).
Unique solutions without sufficient
clinical evidence of success include cryotherapy of the granulation tissue
along lateral nail border, and a metal spring that is glued to the nail plate,
which pulls the nail edge upward. [4]
Surgical Intervention for Ingrown Toenail
Most authorities agree that Stage
III requires surgical intervention. There is much
disagreement, however, regarding the appropriate procedure. Many
methods and techniques have been described in the literature. Techniques
published in the 1920's are still being used.
Most of our experience involves some minor
variations to the procedure described by Pfenninger [5]. After the risks (see
table 2), alternatives, and benefits of the procedure are discussed with the
patient, and consent is obtained, The patient is placed on the table
supine with the ankles extended beyond the tabletop. The toe is painted
with a betadine solution.
A digital block is performed using 5-10 ml
of 1% xylocaine solution without epinepherine: A 25 or 27 guage needle either
1-1.5 inch is used. Pain associated with injection of xylocaine can be
diminished with the use of buffered xylocaine, or EMLA cream applied to the
injection site 2- 30 minutes prior to the procedure. A wheal
is raised at the base of the toe on the dorsal surface and 1-2 ml of anesthetic
is injected in the area of the extensor digital nerve. The needle is
repositioned and advanced towards the plantar surface with 1-2 ml injected in
the area of the plantar digital nerve. The procedure is repeated on the
corresponding site on the opposite side of the toe. (see figure Z) We allow
5-15 minutes for the anesthesia to reach full effect, often seeing a quick
"urgi" visit before returning to complete the procedure.
A rubber band, small Penrose drain, or the
cut of a rubber glove digit may be placed at the base of the toe and used as a
tourniquet. To use the cut end of a glove digit, first cut off the
tip of the digit, and then cut the remaining piece off of the
glove. Place this piece around the toe as far proximally as
possible, and roll the distal cut end of the rubber proximally. This
device can be twisted and looped over the end of the toe once or twice to
obtain the appropriate balance of fit and comfort. In our
experience the procedure also works well without the tourniquet. Keep in
mind however, that if a phenol nail matrix ablation is planned it must be done
in a bloodless field, as any blood will dilute the phenol resulting in a higher
rate of nail growth recurrence.
The nail is loosened from the bed by using
the flat pointed end of a scissors or “anvil style” nail splitters designed for
this procedure (e.g. catalog #243 – Universal Foot Care, Northbrook,
IL). The instrument should be pointed at a slightly upward angle just
under the nail surface to avoid lacerating the nail bed. This is a complication
of the procedure and may require closure with suture if severe. The instrument
is introduced at the hyponychium and pushed back to the nail fold. For a
partial removal loosen the lateral 25% of the nail. A scissors works well for
nail loosening in younger patients. Patients with thicker, or damaged
nails may require a thin periosteal elevator to help avoid laceration of the
nail bed. The scissor or nail splitter is then used to cut the nail along the
margin that has been loosened from the distal tip back to the nail fold.
The nail piece to be removed is grasped medially with a hemostat or needle
driver, and the nail is removed with an upward twisting motion in the direction
of the affected side. After the nail is removed, granulation tissue
should be excised by silver nitrate cautery, trimming with a scissors, or
scalpel.
The exposed nail matrix may be ablated by
various methods. We use Phenol ablation, but techniques using laser,
radiofrequency, and surgical excision have been described. An 88% Phenol
solution is placed on a cotton swab. The bottle of phenol should be
kept in a dark place, with exposure to light minimized, as light will
significantly diminish the effectiveness of the phenol. Old or
light-exposed phenol will be yellow or brown, and fresh phenol will be clear
and colorless. Replace the bottle every one to two months.
The swab should be soaked but not
dripping, and placed in contact with the nail matrix under the proximal nail
fold. We have found that fine tipped, calcium alginate (Ultrafine
Calgiswab, Inolex Corp.) or dacron swabs (Spectrum Laboratories, Inc., Los
Angeles, CA) on the end of a fine, flexible metal wire are optimal. The
swab should remain in contact with the nail matrix for 1-2
minutes. The surrounding normal tissue may be coated with
petroleum jelly prior to the application of phenol as a protective
measure. Simple nail avulsion combined with phenol ablation is more
effective at preventing symptomatic recurrence than avulsion without phenol.
[6] Patient satisfaction is greater with the phenol procedure despite a small
increase in the number of postoperative infections. We have had success with
both procedures. When not performing a phenol ablation we have
the patient put a small amount of cotton or a small piece of waxed dental floss
under the leading edge of the nail as it grows out to prevent recurrence.
This material can be left in place until it falls out, and then simply replaced.
Total nail removal is probably only
necessary when the granulation tissue blocks drainage on both sides of the
nail. If this is the case the nail may be totally loosened, cut in half
and removed in two pieces by the procedure above. An alternative
procedure for total nail removal is described by Birrer et al.: [7] an
elevator is used to free the proximal nail fold and once it is completely free
the elevator is used as a lever to pry the proximal portion of the nail away -
revealing the matrix.
Aftercare of Ingrown Toenail
Most importantly, do not forget to remove
the tourniquet, as this can cause necrosis and loss of the toe! The
patient can’t feel the toe, and may not be able to distinguish postoperative
pain from ischemia in the hours following surgery – especially if the toe is
covered with a dressing. Subsequent postoperative care involves
applying a non-adherent dressing to the nail bed with a gentle compression
dressing over the top. The foot should be elevated as much as possible
for 24 hours. The dressing can then be removed and warm water soaks
started. Pain control is usually adequately achieved with Ibuprophen or
Acetaminophen. It may be necessary to limit weight bearing and wearing shoes
for 2-3 days after the procedure. Shoes with an adequate toe box to allow
the toes to assume a natural position should be worn. The nail typically
grows back in 3-6 months.
