Ingrown toenail

Diagnosis of an Ingrown Toenail

In most cases, the diagnosis of an ingrown toenail (onychocryptosis) is straightforward and does not cause difficulties. The diagnosis can typically be made based on:

• Patient History: Description of pain, previous episodes, nail trimming habits, and footwear.
• Physical Examination: Visual inspection of the affected toe, looking for signs of nail penetration into the skin, inflammation (redness, swelling), presence of pus or discharge, and granulation tissue. Gentle palpation will elicit tenderness along the affected nail border.

Implementation of additional instrumental research methods for an ingrown nail is usually not necessary. However, an X-ray may be considered in rare cases of suspicion of a more extensive purulent process, specifically if there is concern about the spread of infection to the underlying bone (osteomyelitis) of the phalanx, especially in patients with diabetes or compromised immunity, or if there is a history of significant trauma.

Conservative (Non-Surgical) Treatment for Ingrown Toenail

In cases where the symptoms of an ingrown toenail are minimal or in the early stages (mild pain, slight redness, no significant infection or granulation tissue), conservative therapy can be quite effective. The goals are to relieve pressure, reduce inflammation, and guide the nail to grow out correctly.

• Footwear Modification: Reducing pressure on the thumb (big toe) is crucial. This can be achieved by wearing comfortable, wide-toed shoes or open-toed footwear such as sandals. In some instances, avoiding shoes altogether and walking barefoot (in a clean environment) for several days can provide significant relief.
• Proper Nail Trimming Technique:
  • Patients should be educated to cut their toenails straight across, rather than rounding the corners. The corners should be allowed to grow out past the skin edge.
  • Often, to relieve the immediate pain of an ingrown toenail, patients are tempted to cut the nail edge short or dig out the corner. This practice should be **avoided** as it can worsen the problem by creating a sharp nail spicule that further ingrows, leading to a "fishhook-like" deformity and increased pain and inflammation.
• Soaking and Elevation: For patients with ingrown toenails, warm salt water baths (e.g., with Epsom salts) or antiseptic soaks (e.g., with chlorhexidine or povidone-iodine diluted) for 15-20 minutes, 2-3 times a day, can help reduce pain and inflammation, and soften the skin. Elevating the foot can also help reduce swelling.
• Cotton Wick or Dental Floss Packing: A small wisp of cotton or a piece of dental floss can be gently inserted under the ingrown edge of the nail after soaking to lift it away from the skin, encouraging it to grow out over the skin fold. This may need to be repeated daily.
• Topical Antibiotics: If there are early signs of infection of the nail fold (paronychia) with an ingrown nail, topical antibiotics in the form of ointments or creams (e.g., mupirocin, fusidic acid) may be prescribed to apply to the affected area.
• Oral Antibiotics: In more severe cases of infection with significant cellulitis or purulent discharge, a patient with an ingrown toenail may be prescribed a course of systemic (oral) antibiotic therapy.
• Taping: Sometimes, taping the skin of the nail fold away from the ingrown nail edge can provide relief and help guide nail growth.

Surgical Treatment for Ingrown Toenail

Indications for Surgery

Surgical intervention for an ingrown toenail may be required if:

• Conservative treatments fail to provide relief.
• There is recurrent ingrowth despite conservative measures.
• Significant infection, abscess formation, or extensive granulation tissue ("proud flesh") develops as a result of chronic inflammation.
• Severe pain or deformity significantly impacts daily activities.
• Hypertrophy (thickening and overgrowth) of the tissues of the nail fold occurs due to chronic irritation.

Surgical Procedures

Several surgical procedures can be performed, usually under local anesthesia (digital nerve block). The choice of procedure depends on the severity and chronicity of the condition, as well as surgeon preference.

• Partial Nail Avulsion (Wedge Resection): This is a common procedure. The ingrown lateral portion of the nail plate is removed, often along with the corresponding portion of the nail bed and underlying germinal matrix (the area from which the nail grows) to prevent regrowth of that segment. This can be done by sharp excision or sometimes using chemical ablation (e.g., with phenol or sodium hydroxide) or electrocautery/laser ablation of the matrix.
• Nail Fold Excision (Soft Tissue Excision): In mild cases with hypertrophy of the nail fold, removing a wedge of the overgrown soft tissue alongside the nail can reduce symptoms of inflammation and irritation, allowing the nail to grow more freely. Within a few months after this type of surgery for an ingrown nail, the shape of the nail plate and surrounding tissue often normalizes.
• Total Nail Avulsion: Complete removal of the entire toenail plate. This is generally reserved for cases of severe nail deformity, extensive infection involving the entire nail bed, or recurrent ingrowth after less invasive procedures. However, the nail will regrow, and if the underlying cause (e.g., nail shape, matrix issues) is not addressed, ingrowth can recur.
• Matrixectomy (Germinal Matrix Ablation): If permanent removal of the nail or a portion of it is desired (e.g., in cases of severe, recurrent deformity or chronic pain), the germinal matrix responsible for nail growth is destroyed, either surgically (excision) or chemically (e.g., with phenol). After this operation, regeneration of that part of the nail plate does not occur. Such a radical operation for an ingrown nail is performed relatively rarely and only for specific, severe indications.

In more severe or recurrent cases of an ingrown toenail, it may be necessary to remove part of the nail plate along with the corresponding segment of the germinal area (matrixectomy) to achieve a permanent solution for that border.

Differential Diagnosis of Toenail Pain and Inflammation

While ingrown toenail is common, other conditions can cause pain and inflammation around the toenail:

 

Potential Complications of Ingrown Toenails

If left untreated or improperly managed, ingrown toenails can lead to several complications:

• Infection (Paronychia/Cellulitis): Bacterial infection of the surrounding soft tissues is common, leading to increased pain, redness, swelling, and pus formation.
• Abscess Formation: A localized collection of pus may form.
• Granulation Tissue (Proud Flesh): Chronic irritation can lead to the formation of highly vascular, friable granulation tissue at the site of ingrowth, which bleeds easily.
• Chronic Pain and Discomfort: Making walking and wearing shoes difficult.
• Osteomyelitis: Rarely, severe or neglected infections can spread to the underlying bone of the phalanx. This is more common in individuals with diabetes or compromised circulation.
• Nail Deformity: Chronic ingrowth or repeated infections can lead to permanent changes in nail shape or thickness.
• Spread of Infection: In immunocompromised individuals or those with poor circulation (e.g., diabetes, peripheral vascular disease), infection can spread more extensively.

 

Prevention of Ingrown Toenails

Preventive measures can significantly reduce the risk of developing ingrown toenails:

• Proper Nail Trimming: Cut toenails straight across, not too short, and avoid rounding the corners. Use clean, sharp nail clippers. Gently file any sharp edges.
• Appropriate Footwear: Wear shoes that fit properly and provide adequate room in the toe box. Avoid shoes that are too tight, narrow, or have high heels that compress the toes.
• Foot Hygiene: Keep feet clean and dry to prevent skin maceration and infections.
• Protect Feet from Trauma: Wear sturdy shoes when engaging in activities that could injure the toes.
• Address Underlying Conditions: Manage conditions like onychomycosis (fungal nail infections) promptly.
• Professional Care: Individuals with diabetes, poor circulation, or nerve damage in their feet should seek professional foot care (podiatrist) for nail trimming and management.

 

When to Seek Medical Attention

It is advisable to seek medical attention from a doctor or podiatrist for an ingrown toenail if:

• There are signs of infection (increasing redness, warmth, swelling, pus, fever).
• The pain is severe or not relieved by home care measures.
• The condition is recurrent.
• Home care attempts (e.g., soaking, gentle lifting of nail edge) have not improved the condition within a few days.
• The individual has diabetes, peripheral vascular disease, or any condition that impairs circulation or healing, as these increase the risk of severe complications.
• There is significant granulation tissue formation.
• Uncertainty about proper self-care or nail trimming.

A healthcare professional can provide an accurate diagnosis, recommend appropriate treatment (conservative or surgical), and help prevent recurrence.