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The Blackburn Foot and Ankle Hyperbook  
Evidence based education in foot and ankle surgery
  Ingrowing toenail

An ingrown nail (onychocryptosis) occurs when the edge of the toenail digs into, and pierces, the skin adjacent to the nail. The skin may present as inflamed, swollen and is almost always tender. Opportunistic infections can occur from the normal skin flora. Infection always exacerbates the lesion as further swelling gives rise to further pressure and a likelihood of increased penetration of the nail.

The debilitating effects of an ingrown nail must never be underestimated. One of the first papers published on the operative management captures the sentiment well. “One of the most painful and incapacitating conditions encountered in the field of minor surgery, which can be relieved with gratifying results by proper surgical treatment, is the ingrown toenail” (Winograd 1929)

Epidemiology

Studies in the United Kingdom have shown a 2:1 male to female ratio, most commonly affecting patients aged 16-25 years old (Langford 1989). In the USA the 1990 National Health Survey showed a 2:1.5 male to female ratio for patients younger than 45 years old; with increasing age more female patients suffered. Over 75 years of age the male to female ratio reduced to 1:1.6. (Levy 1992).

Aetiology

Ingrown nails have been reported to occur for a variety of reasons:

  • Ill-fitting footwear
  • Tight socks
  • Soft tissue abnormalities of the toe
  • Abnormal foot mechanics
  • Excessive sweating (hyperhydrosis)
  • Incorrect trimming of the nail (cutting, or not cutting, the lateral nail edge)

(Lloyd-Davies 1963).

Langford (1989) concurred with Lloyd-Davies but also included:

  • Thick nail folds
  • Medial rotation of the hallux (eversion)
  • Reduced nail thickness

Diabetic patients have been found to have a higher incidence of ingrown nails compared with non-diabetic patients (Riviera 1998).

Ingrown nails have been reported to occur secondary to medicinal intervention. Patients with HIV infection, being treated with protease inhibitors have presented with multiple ingrown nails. Indinavir is the main protease inhibitor that has been implicated (Bouscarat 1998, Alam M 1999, Bourezane 1999). The immunosuppressive drug, Cyclosporin has been associated with the development of ingrown nails (Olujohungbe 1993). Similarly oral antifungal treatment has been associated with ingrown toenails (Connelly 1999), (Weaver and Jespersen 2000).

Clinical features

Most patients present with pain, swelling and difficulty with shoewear. All patients should be asked about possible underlying causes of chronic infection, such as diabetes and steroid use.

The foot should be examined for mechanical factors which might precipitate nail pressure or infection. Inspect the shoes – they may be the main source of pressure. Look for tenderness in the pulp or proximally, which may indicate osteomyelitis.

Differential diagnosis includes subungual exostosis, primary osteomyelitis of the phalanx and tumours of the nail bed, including subungual melanoma.

An ingrown nail affecting the fibular sulcus of the left hallux
A longstanding presentation affecting both sulci of both hallux nails

Classification

There is no consensus on the classification of the lesion at presentation. The most frequent classification quoted in the literature is that first proposed by Heifetz (1937) and subsequently used by Mogensen (1971).

  • Grade 1: Pain, reddening and slight swelling of the nail sulcus.
  • Grade 2: As above, accompanied by infection and suppuration.
  • Grade 3: As above with the formation of granulation tissue (sometimes referred to as hypergranulation tissue.

Infection and suppuration is more marked in grade 3. Untreated ingrown toenails can have serious and limb threatening consequences. Cox and Jones (1995) reported development of osteomyelitis as a consequence of chronic ingrown toenails. Tumours, primary or metastatic, can mimic the presentation of an ingrown toenail (Goldenhersh 1992, Requena 1993, Lemont 2002).

Treatment

Self treatment

Trimming toenails
correct
incorrect

To avoid ingrown toe nails, it is advisable not to cut the nails too short. Patients often believe that it is best to cut toe nails ‘straight across’, this would leave sharp corners of nail which could possibly cut into the adjacent toe. The correct advice would be to cut the nail following the outline of the end of the digit ensuring that when cut the whole of the leading edge of the nail is still visible. See Fig 3. It is preferable to use nail clippers rather than scissors. Scissors have a slicing action which can be painful. In patients who are not confident using sharp instruments, the nail can be shortened using an ‘Emery board’ or abrasive file.

Non-operative treatment

Conservative treatment is indicated for all grade 1 presentations and some grade 2. Treatment is restricted to debridement of the affected nail. Some practitioners pack the affected sulcus with cotton gauze; as described by Reijnen and Goris (1989).

If interdigital pressure appears to be an aggravating factor, the use of an interdigital spacer has been reported as successful (Gunal 2003).

Antibiotics are often prescribed for infected ingrowing toenails. While this may be appropriate to control acute symptoms, patients often have further problems and antibiotics should not be seen as a long-term solution. Reyzelman et al (2000) showed that periprocedural antibiotics did not improve the outcome of phenol matricectomy, even if given a week before to allow the infection time to resolve before the main procedure.

Operative Treatment

Surgical treatment is indicated in all grade 3 presentations and some of the worst grade 2 presentations. It may also be indicated in other nail conditions which present with discomfort or pain:

  • pincer nails, sometimes referred to as involuted nails
  • symptomatic onychomycosis which has failed oral antifungal treatment
  • onychogryphosis
  • onychauxis (Ceilley 1992).

Contraindications

Patients must be assessed to ensure adequate blood supply to ensure wound healing. Physical signs of ischaemia include absent posterior tibial and dorsalis pedis pulses, slow capillary filling time, skin atrophy and absence of skin hair. Patients with an ankle brachial index below 0.5 or toe pressures below 40mm Hg are at risk of non-healing (Giacalone 1997).

Preoperative assessment

In most cases patients do not require laboratory testing prior to nail surgery (Siegle 1992). If a subungual exostosis or bony abnormality is suspected, plain film radiographs are indicated. Radio-isotope studies may be useful if osteomyelitis is suspected, especially in chronic ingrown nails (Cox 1995). Subungual glomus tumours can be detected with magnetic resonance imaging (Holzberg 1992).

Anaesthesia

A local anaesthetic ring block technique is all that is required for routine toenail surgery. Sedation and general anaesthesia is reserved for uncooperative patients or the very young (Dixon 1983, Murray 1989). Lidocaine or bupivicaine is generally used. Bupivicaine has a longer duration of action and therefore provides greater postoperative pain relief. Vasoconstrictors, such as epinephrine, must be avoided in extremities.

A variety of procedures have been advocated. Some procedures require full surgical theatre facilities, where as others can be performed in a clean clinical setting following aseptic techniques.

"Sharp" procedures (requiring theatre)

  • Surgical excision of the nail sulcus, plate, bed and matrix - Winograd (1929)
  • Surgical excision of the germinal epithelium - Zadik (1950)
  • “Terminal Syme’s procedure” as described by Lapidus (1933) – as above with amputation of the distal half of the distal phalanx, named by analogy with the Syme’s amputation of the foot.

In Winograd’s original paper he reported no recurrences of the ingrown nail. Later studies have reported recurrence rates of between 11% and 27% (Keyes E 1934, Murray and Bedi 1975, Issa et al 1988, Van Der Ham et al 1990).

Zadik reported no recurrences but 2 cases of postoperative necrosis. Further studies of this technique have reported recurrence of nail spicules at a rate from 27% to 50% (Townsend and Scott 1966, Murray and Bedi 1975, Palmer and Jones 1979).

The Symes procedure has reported postoperative spicules. Thompson and Terwilliger (1951).

Chemical matrixectomy (requiring clean room)

Two chemical have been described in chemical ablation of the germinal nail matrix; sodium hydroxide and phenol (Travers and Ammon 1980). The use of phenol is most commonly reported. Reports of phenol use occur as early as 1901 with Porter, and Boll introduced this technique formally in 1945. This procedure has lower recurrence rates, reports range from 3.9% to 10% (Morkane et al 1984, Issa and Tanner 1988, Van Der Ham et al 1990, Mori et al 1998, Herold 2001).

Which procedure?

A number of RCTs have compared surgical techniques. Greig (1991) found a 73% recurrence rate after both total nail avulsion and wedge excision of the nail, but only 9% after phenol matricectomy. Simple avulsion of the whole nail or a wedge should not not be a standard treatment; if surgery is necessary the germinal matrix should be ablated at the first procedure.

Other trials (Issa + Tanner 1988, Herold 2001, Gerritsma-Bleeker 2002) have compared surgical and chemical matricectomy. Recurrence rates were similar, although there was a trend for less revision surgery after chemical ablation. Combined surgical and chemical matricectomy was found by Issa and Tanner to have fewer recurrences than either surgery or chemical ablation alone, and this is the technique we use.

Post-operative complications

Recurrence rates with phenol matricectomy are low, but nail spicules have occurred following this procedure. The main complication can be superficial chemical burns. There is one reported case of amputation of the distal phalanx of a big toe following a chemical burn induced during nail surgery (Sugden and Levy 2001).

Conclusion

This review has examined the current evidence surrounding the incidence and treatment for ingrown toe nails. Stage 1 and some Stage 2 presentations can be managed with conservative measures. Some Stage 2 and all Stage 3 presentations are best managed surgically. Of all the procedures available for surgical management, phenol matricectomy, possibly combined with surgical matricectomy appears to offer the best results.

References

  • Alam M, Scher RK. Indinavir-related Recurrent Paronychia and Ingrown Nails. Cutis. 1999; 64: pp 277-278.
  • Boll O. Surgical Correction of Ingrowing Nails. Journal of the National Association of Chiropodists. 1945; 35: 8.
  • Bourezane Y Thalamy B, Viel J et al. Ingrown Toenail and Indinavir: A Case Control Study Demonstrates Strong Relationship. AIDS. 1999; 22: pp 2181-2182.
  • Bouscarat F, Bouchard C, Bouhour D. Paronychia and Pyogenic Granuloma of the Great Toes in Patients Treated with Indinavir. New England journal of Medicine. 1998; 338: pp 1776-1777.
  • Ceilley R, Collinson D. Matrixectomy. Journal of Dermatology, Surgery and Oncology. 1992; 18: pp 728-734.
  • Connelly L, Dinehart S, McDonald R. Onychcryptosis Associated with the Treatment of Onychomycosis. Journal of the American Podiatric Medical Association. 1999; 89: pp 424-426.
  • Connolly A, Meyer L, Tate J. Local Anesthetic Agents in Surgery for Ingrown Toenail. British Journal of Surgery. 1993; 81: pp425-426.
  • Cox H, Jones R. Direct Extension Osteomyelitis Secondary to Chronic Onychocryptosis. Journal of the American Podiatric Medical Association. 1995; 85: pp 321-324.
  • Dixon G. Treatment of Ingrown Toenail. Foot and Ankle. 1983; 3: pp 254-260.
  • Giacalone V. Phenol Matrixectomy in Patients with Diabetes. Journal of Foot and Ankle Surgery. 1997; 36: pp 264-267.
  • Goldenhersh M, Prus D, Ron N et al. Merkel Cell Tumour Masquerading as Granulation Tissue on a Teenager’s Toe. American Journal of Dermatopathology. 1992; 14: pp 560-563.
  • Gunal I, Kosay C Veziroglu A et al. Relationship Between Onychocryptosis and Foot Type and Treatment with a Toe Spacer. Journal of the American Podiatric Medical Association. 2003; 93: pp 33-36.
  • Heifetz CJ. Ingrown Toenail. American Journal of Surgery. 1937; 38: pp 298-315.
  • Herold N, Houshian S, Reigels-Nielsen P. A Prospective Comparison of Wedge Matrix Resection with Nail Matrix Phenolisation for the Treatment of Ingrowing Toenail. Journal of Foot and Ankle Surgery. 2001; 40: pp 390-395.
  • Holzberg M. Glomus Tumour of the Nail: a “Red Herring” Clarified by Magnetic Resonance Imaging. Archives of Dermatology. 1992; 128: pp 160-162.
  • Issa M, Tanner W. Approach to Ingrowing Toenails: The Wedge Resection/Segmental Phenolisation Combination Treatment. British Journal of Surgery. 1988; 75: pp 181-183.
  • Keyes E. The Surgical Treatment of Ingrown Toenails. Journal of the American Medical Association. 1934; pp 1458-1460.
  • Langford DT, Burke C, Robertson K. Risk Factors in Onychocryptosis. British Journal of Surgery. 1989; 76: pp45-48.
  • Lapidus P. Complete and Permanent Removal of the Toenail in Onychogryphosis and Subungual Osteoma. American Journal of Surgery. 1933; 19: pp 92-94.
  • Lemont H, Brady J. Amelanotic Melanoma Masquerading as an Ingrown Toenail. Journal of the American Podiatric Medical Association. 2002; 92: pp 306-307.
  • Levy L. Prevalence of Chronic Podiatric Conditions in the US. National Health Survey 1990. Journal of the American Podiatric Medical Association. 1992; 82: pp 221-223.
  • Lloyd-Davies R, Brill G. The Aetiology and Outpatient Management of Ingrowing Toenail. British Journal of Surgery. 1963; 50: pp 592-597.
  • Mogensen P. Ingrowing Toenail. Acta Orthop Scand. 1971; 42: pp 94-101.
  • Morkane A, Robertson R, Inglis G. Segmental Phenolisation of Ingrowing Toenails; a Randomised Controlled Study. British Journal of Surgery. 1984; 71: pp 526-527.
  • Murray W. Management of Ingrowing Toenails. British Journal of Surgery. 1989; 76: pp 883-885.
  • Murray W, Bedi B. The Surgical Treatment of Ingrowing Toenail. British Journal of Surgery. 1975; 62: pp 409-412.
  • Olujohungbe A, Cox J, Hammon M et al. Ingrowing Toenails and Cyclosporin. Lancet. 1993; 342: pp 1111.
  • Palmer B, Jones A. Ingrowing Toenails: the Results of Treatment. British Journal of Surgery. 1979; 66: pp 575-576.
  • Porter F. Ingrowing Toe-nail. British Medical Journal. 1901; 2: 476.
  • Reijnen JAM, Goris RJA. Conservative Treatment of Ingrowing Toenails. British Journal of Surgery. 1989; 76: pp 955-957.
  • Riviera A. Risk Factors for Amputation in Diabetic Patients: A Case Controlled Study. Archives of Medical Research. 1998; 29 pp 179-184.
  • Siegle R, Stewart R. Recalcitrant Ingrowing Nails: Surgical Approaches. Journal of Dermatology, Surgery and Oncology. 1992; 18: pp 744-752.
  • Sugden P, Levy M. Onychocryptosis-phenol fiasco: a case report. Burns. 2001; 27: pp 289-292.
  • Thompson T, Terwilliger C. The Terminal Symes Operation for Ingrown Toenail. Surgical Clinics of North America. 1951; 31: pp 575-584.
  • Townsend A, Scott P. Ingrowing Toenail and Onychogryphosis. British Journal of Bone and Joint Surgery. 1966; 48: pp 354-358.
  • Travers G, Ammon R. The Sodium Hydroxide Chemical Matricectomy Procedure. Journal of the American Podiatric Medical Association. 1980; 70: pp 476-478.
  • Van Der Ham A, Hackeng C, Yo I. The Treatment of Ingrowing Toenails. British Journal of Bone and Joint Surgery. 1990; 72: pp 507-509.
  • Weaver T, Jespersen D. Multiple Onychocryptosis Following Treatment of Onychomycosis with Oral Terbinefine. Cutis. 2000; 66: pp 211-212.
  • Winograd A. A Modification in the Technic of Operations for Ingrown Toe-nail. Journal of the American Medical Association. 1929; pp 229-230.
  • Zadik F. Obliteration of the Nail Bed of the Great Toe Without Shortening the Terminal Phalanx. British Journal of Joint and Bone Surgery. 1950; 32B: pp 66-67