Am Fam Physician. 2009 Feb fifteen;79(4):303-308.

Patient data: See related handout on ingrown toenails, written by the authors of this commodity.

Article Sections

  • Abstract
  • Causes and Run a risk Factors
  • Presentation
  • Treatment
  • Conservative Therapy
  • Surgical Therapy
  • Approach to the Patient
  • Complications
  • References

Ingrown toenail, or onychocryptosis, most unremarkably affects the dandy toenail. Many anatomic and behavioral factors are thought to contribute to ingrown toenails, such as improper trimming, repetitive or inadvertent trauma, genetic predisposition, hyperhidrosis, and poor foot hygiene. Conservative treatment approaches include soaking the foot in warm, soapy water; placing cotton wisps or dental floss under the ingrown nail border; and gutter splinting with or without the placement of an acrylic nail. Surgical approaches include partial nail avulsion or complete smash excision with or without phenolization. Electrocautery, radiofrequency, and carbon dioxide laser ablation of the boom matrix are also options. Oral antibiotics before or after phenolization do not improve outcomes. Fractional nail avulsion followed by either phenolization or direct surgical excision of the smash matrix are equally effective in the treatment of ingrown toe-nails. Compared with surgical excision of the nail without phenolization, fractional nail avulsion combined with phenolization is more effective at preventing symptomatic recurrence of ingrowing toenails, simply has a slightly increased risk of postoperative infection.

Approximately 20 percent of patients presenting to a family doc with a foot problem accept an ingrown toenail, besides known every bit onychocryptosis.1 Ingrown toenails occur when the periungual skin is punctured by its respective nail plate, resulting in a cascade of foreign body, inflammatory, infectious, and reparative processes.2 Ultimately, this may result in a painful, draining, and foul-smelling lesion of the involved toe (most normally, the hallux blast), with soft tissue hypertrophy around the nail plate.

SORT: Central RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Conservative approaches for the treatment of ingrown toenails without infection include placing a cotton wisp, dental floss, or gutter splint (with or without acrylic nail) under the ingrown nail border.

C

12

Oral antibiotics earlier or after phenolization do non decrease healing rates or postprocedure morbidity in the treatment of ingrown toenails.

B

1

Partial nail avulsion followed by phenolization or direct surgical excision of the nail matrix are equally effective in the treatment of ingrown toenails.

B

xvi

Compared with surgical excision of the nail without phenolization, partial smash avulsion combined with phenolization is more effective at preventing symptomatic recurrence of ingrown toenails, but has a slightly increased take a chance of postoperative infection.

B

8

Causes and Run a risk Factors

  • Abstract
  • Causes and Risk Factors
  • Presentation
  • Treatment
  • Conservative Therapy
  • Surgical Therapy
  • Arroyo to the Patient
  • Complications
  • References

Based on clinical experience, ingrown toe-nails are thought to exist caused past improper blast trimming or tearing nails off ( Effigy 1 ). Because of poor visualization or instrumentation, a barb is created that anchors itself in the soft periungual tissues and penetrates deeply equally the blast plate grows distally. Force during ambulation, pressure from constricting footwear, and obesity (if present) drive the nail affront penetration and worsens its severity.2

Figure 1.

Examples of improper and proper toenail trimming. Toenails should be cutting straight across, and the corners should not exist rounded off.

Risk factors predisposing to development of ingrown toenails include anatomic and behavioral mechanisms. Some experts suggest that wider nail folds and thinner, flatter nails increase the risk of ingrown toenails,3 only this remains unproven. A case-control report with 46 patients found no difference in the anatomic shape of toenails in patients with and without ingrown toenails.4 Repetitive trauma (e.g., running, kicking) or inadvertent trauma (east.1000., stubbing the toe) may be inciting factors.5

Without any strict evidence basis, it is idea that a genetic predisposition and family history,three hyperhidrosis, and poor foot hygiene increase the likelihood of ingrown toenails.6 Diabetes, obesity, and thyroid, cardiac, and renal disorders that may predispose to lower extremity edema can also increment the likelihood.7

In adolescence, feet perspire more often, causing the skin and nails to go soft, resulting in like shooting fish in a barrel splitting. This produces blast spicules that can pierce the lateral pare. In older persons, spicule formation tin become a chronic problem caused by their reduced ability to care for their nails secondary to reduced mobility or impaired vision. In improver, the natural aging procedure causes toenails to thicken, making them more difficult to cut and more inclined to exert pressure level on the lateral skin at the sides of the nail plate, often becoming ingrown, painful, and infected.8

Presentation

  • Abstract
  • Causes and Risk Factors
  • Presentation
  • Treatment
  • Conservative Therapy
  • Surgical Therapy
  • Approach to the Patient
  • Complications
  • References

Ingrown toenails are classified into 3 categories: balmy, moderate, and severe. Mild cases are characterized by nail-fold swelling, erythema, edema, and hurting with pressure. Moderate cases are associated with increased swelling, seropurulent drainage, infection, and ulceration of the nail fold. The most astringent cases of ingrown toenail exhibit chronic inflammation and granulation, every bit well as marked nail-fold hypertrophy.nine,10

Treatment

  • Abstract
  • Causes and Run a risk Factors
  • Presentation
  • Treatment
  • Conservative Therapy
  • Surgical Therapy
  • Approach to the Patient
  • Complications
  • References

Indications for the treatment of an ingrown toenail include meaning hurting or infection; onychogryposis (a deformed and curved nail); or chronic, recurrent paronychia (inflammation of the nail fold). Contraindications to surgical treatment include an allergy to local anesthetics (e.g., lidocaine [Xylocaine], bupivacaine [Marcaine]), a known bleeding diathesis, or pregnancy (in the case of phenol utilize).11 Conservative and surgical treatment options exist and should exist presented to the patient with respect to risks, benefits, alternatives, and patient preference ( Figure 2 ).one,xi–17

Management of the Ingrown Toenail

Figure ii.

Algorithm for a suggested approach to the patient with an ingrown toenail.

Information from references 1 and 11 through 17.

Conservative Therapy

  • Abstract
  • Causes and Hazard Factors
  • Presentation
  • Treatment
  • Conservative Therapy
  • Surgical Therapy
  • Arroyo to the Patient
  • Complications
  • References

Although clinical trials proving its value practise not exist, conservative therapy is a reasonable approach in patients with a mild to moderate ingrown toenail who do not have significant pain, substantial erythema, or purulent drainage from the lateral nail edge. Bourgeois therapy provides a toll-effective approach that obviates the need for a minor surgical procedure and its attendant brusk-term small-scale inability and pain. One conservative treatment pick is to soak the affected toe and pes for ten to 20 minutes in warm, soapy water. Afterwards each soak, proficient recommendation is to apply a topical antibiotic ointment (e.g., polymyxin/neomycin [Neosporin]) or a mid- to high-potency steroid cream or ointment to the affected area several times daily for a few days until resolution.12

Wisps of cotton placed under the ingrown lateral nail edge using a nail lift or a small curette can too exist attempted, with the patient repeating this process if the cotton fiber falls out.12 An uncontrolled example serial found a 79 percent rate of symptomatic improvement using cotton wool wisps over a mean follow-upward period of 24 weeks.13 There is no evidence to suggest that inserting cotton wisps underneath an ingrown boom border harbors bacteria or potentially increases the hazard of infection. Dental floss inserted obliquely under the ingrown blast corner has also been found to be effective in mild to moderate cases, producing minimal, if any, hurting and no secondary infection, with well-nigh firsthand relief from hurting and the ability to resume normal activities.xiv

Some other conservative handling approach is to use a gutter splint (due east.g., a sterilized vinyl intravenous drip infusion tube slit from top to bottom with one finish cut diagonally for polish insertion) that can exist affixed to the ingrown boom edge with either agglutinative tape or a formable acrylic resin such as cyanoacrylate15 ( Figure three ). A sculptured acrylic artificial smash can as well exist used in patients with an ingrown nail and no granulation tissue. A plastic nail platform is placed under the nail and fixed with adhesive record. Formable acrylic is and then placed on the nail and platform and molded into a smash shape to cover either a portion or the unabridged nail area surface. Treatment duration depends on the time required for the normal nail to grow over the tip of the toe, which is approximately 2 weeks to three months.

Figure 3.

Gutter splint treatment for ingrown toenails.

Surgical Therapy

  • Abstract
  • Causes and Adventure Factors
  • Presentation
  • Treatment
  • Conservative Therapy
  • Surgical Therapy
  • Arroyo to the Patient
  • Complications
  • References

With proper training, family physicians can treat ingrown toenails without referral to a human foot specialist. The most common procedure to treat locally infected ingrown toenails is partial avulsion of the lateral edge of the smash followed by chemical matricectomy using fourscore to 88% phenol (phenolization).

ADJUNCTIVE ANTIBIOTICS

Infections of the lateral nail fold are most ordinarily acquired by Staphylococcus aureus and less ofttimes by Gram-negative species (east.grand., Pseudomonas) and Streptococcus species. Although the use of oral antibiotics before or after phenolization is widespread, their use is based solely upon historic practice without bear witness from clinical trials. Several studies have indicated that once the ingrown portion of the boom is removed and matricectomy is performed, the localized infection will resolve without the need for antibiotic therapy.18,nineteen 1 randomized controlled trial with 54 patients found no significant difference in healing times betwixt a group that received concomitant antibiotics and phenolization compared with a group that received phenolization alone over 2 to three weeks.1 Initial treatment with oral antibiotics earlier surgical therapy has not been shown to decrease healing times and may delay matricectomy in moderate to astringent cases, which tin ultimately increase the time until clinical healing.1 Physicians should strongly consider withholding antibiotic treatment and proceeding to matricectomy if bourgeois therapy is not an option.

Destruction OF THE MATRIX

Although phenol has antiseptic and coldhearted backdrop, information technology may crusade tissue impairment and possibly infection, delaying postoperative healing.twenty The best evidence demonstrates that partial blast avulsion followed by phenolization or straight surgical excision of the nail matrix are equally effective in the treatment of ingrown toenails.sixteen Another study found that partial smash avulsion with phenolization yielded better results than partial avulsion with nail matrix excision.21 In the latter study, local antibiotics did not reduce the risk of infection or recurrence of the ingrown toenail, and phenolization did non increment the risk of infection more than matrix excision.21 A Cochrane systematic review found that fractional nail avulsion combined with phenolization is more than constructive at preventing symptomatic recurrence than surgical excision without phenolization, simply has a slightly increased risk of postoperative infection.8 Trials evaluating different treatment methodologies have not adequately assessed patient satisfaction because follow-up time in each trial was less than six months, which is not an adequate time period to measure symptomatic recurrence. Although phenolization may exist the most appropriate and beneficial treatment for most patients, risks and benefits should exist discussed with each patient.

SURGICAL Approach

Unilateral matricectomy is effective and advisable in nearly cases, but contralateral ingrown toenail may develop over time equally the remaining portion of the nail plate spontaneously repositions itself.22 Bilateral partial matricectomy maintains the functional role of the nail plate (although narrowing it) and preserves its cosmetic role; therefore, it should be considered in patients with severe ingrown toenail or recurrences.23 Excessive phenolization affecting next tissues may cause serous oozing for up to five to six weeks after the procedure. The use of twenty% ferric-chloride–soaked sterile cotton application for 20 to xxx seconds to the exposed nail bed has been plant to reduce nail bed oozing, merely carries a pocket-sized risk of inducing local thrombosis.ten

ALTERNATIVE PROCEDURES

Fractional matricectomy via electrocautery, radiofrequency, and carbon dioxide laser ablation are all constructive options in the treatment of ingrown toenails. Advantages of these techniques include less bleeding, reduced postoperative pain, and immediate sterilization of infected tissue. The carbon dioxide laser offers the advantage of express thermal impairment to adjacent tissues. Disadvantages include a usually prolonged flow for reepithelization and healing of the tissues by secondary intention and, consequently, local wound care for up to six weeks.22 Staining of the nail matrix with methylene blue before performing a partial matricectomy with the carbon dioxide laser allows for better visualization of the nail matrix and tin can ensure complete cauterization.xx Matricectomy via these methods is more expensive because of the initial investment of equipment costs. To date, in that location have been no comparative trials to examine toll-effectiveness of either conservative or surgical treatment options.9

Arroyo to the Patient

  • Abstruse
  • Causes and Risk Factors
  • Presentation
  • Treatment
  • Conservative Therapy
  • Surgical Therapy
  • Arroyo to the Patient
  • Complications
  • References

Figure two provides a suggested arroyo to the patient with ingrown toenail.1,11–17 Table one summarizes the technical details of surgery.8,12,17

Table 1.

Surgical Approach to the Ingrown Toenail

  1. Obtain surgical consent later explaining to the patient the risks, benefits, and alternatives. Place the patient in a supine or seated position with the affected toe (Figure iv) and foot hanging off the end of the table.

  2. Prepare the affected toe with standard povidone iodine solution. Apply lidocaine (Xylocaine) or bupivacaine (Marcaine) without epinephrine for local anesthesia in a digital block fashion.

  3. Apply a tourniquet or rubber ring effectually the toe to assist in hemostasis for simply a short duration; apply with caution in patients with known peripheral vascular affliction or diabetes (Figure 5).

  4. Identify the lateral twenty to 25 pct of the ingrown boom as the site of the fractional lateral nail avulsion. Utilise a nail elevator nether the boom to split up information technology from the nail bed (Figure 6).

  5. Use a nail splitter to cutting from the distal end of the toenail straight dorsum toward the cuticle beneath the boom fold (Figure seven).

  6. Grasp the avulsed lateral nail fragment with a hemostat downwardly to just by the cuticle. Remove it by twisting the avulsed smash outward toward the lateral blast fold while pulling in a directly direction toward the end of the toe. Ensure that the unabridged nail fragment and flat edge of the nail bed is retrieved to forestall formation of a nail spicule and the potential for recurrence of an ingrown nail.

  7. Release the tourniquet subsequently acceptable hemostasis is accomplished. Options for destruction of the blast-forming matrix beneath where the nail plate was removed include phenolization or mechanical destruction of the nail matrix. For phenolization, employ an 80 to 88% phenol solution directly to the blast matrix three times for 30 seconds each round (Figure 8). Then, thoroughly cleanse with 70% isopropyl booze to neutralize the phenol. Apply phenol only to the matrix and not the nail bed or surrounding tissue, which may filibuster wound healing. Phenol should not be used if the patient, physician, or medical administration may be pregnant. Options for destruction of the nail matrix, likewise as for removal of any adjacent granulation tissue, include electrocautery, radiofrequency, and carbon dioxide laser ablation.

  8. After surgery, apply a dressing of antibody ointment (east.g., bacitracin/polymyxin [Polysporin]), 4 Ten 4 gauze, tube gauze, and paper tape, ensuring a comfortable cast (variations on materials are adequate; these recommendations are expert opinion).

  9. After 24 to 48 hours, soak the afflicted toe in warm, soapy water and reapply antibiotic ointment and a clean bandage. This should be washed three to four times daily for ane to two weeks after the procedure.

Effigy 4.

Ingrown left groovy toenail (medial correct edge of the nail).

Figure 5.

Awarding of tourniquet

Figure 6.

Separation of the smash from the nail bed with a nail elevator.

Figure vii.

Cutting the ingrown portion of the nail with a nail splitter.

Figure 8.

Application of phenol to the nail matrix.

Complications

  • Abstract
  • Causes and Take a chance Factors
  • Presentation
  • Treatment
  • Conservative Therapy
  • Surgical Therapy
  • Approach to the Patient
  • Complications
  • References

An incomplete matricectomy can result in a regrowth of a smash spicule forth the new lateral blast fold. This new nail growth results in an inflammatory reaction, often necessitating another process. If infection of the lateral nail fold is suspected, physicians should prescribe an oral antibiotic that covers common peel flora (e.g., cephalexin [Keflex] 500 mg orally iv times daily for v to vii days).11 Overaggressive electrocautery or radiofrequency ablation to the nail matrix may damage the adjacent and underlying fascia or periosteum. If the toe is healing poorly several weeks afterward the procedure, debridement, oral antibiotics, and radiographic evaluation may exist warranted.12

Patients should be instructed earlier the procedure that the appearance of the affected nail will be permanently contradistinct and that the recess created by the removal of the blast and granulation tissue volition gradually resolve to a somewhat normal advent.

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The Authors

prove all author info

JOEL J. HEIDELBAUGH, MD, is a clinical banana professor in the Departments of Family Medicine and Urology, and the clerkship director in the Department of Family Medicine at the Academy of Michigan, Ann Arbor. He received his medical degree from Upstate Medical University, and completed his residency at St. Joseph's Hospital Health Center, both in Syracuse, NY....

HOBART LEE, MD, is co-chief resident in the Section of Family Medicine at the University of Michigan. He received his medical degree from the University of Pennsylvania, Philadelphia.

Address correspondence to Joel J. Heidelbaugh, MD, Ypsilanti Health Center, 200 Arnet, Suite 200, Ypsilanti, MI 48198 (e-post: jheidel@umich.edu). Reprints are not bachelor from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

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1. Reyzelman AM, Trombello KA, Vayser DJ, Armstrong DG, Harkless LB. Are antibiotics necessary in the treatment of locally infected ingrown toenails? Curvation Fam Med. 2000;nine(ix):930–932. ...

2. DeLauro NM, DeLauro TM. Onychocryptosis. Clin Podiatr Med Surg. 2004;21(4):617–630.

3. Langford DT, Burke C, Robertson K. Gamble factors in onychocryptosis. Br J Surg. 1989;76(i):45–48.

4. Pearson HJ, Bury RN, Wapples J, Watkin DF. Ingrowing toenails: is at that place a nail aberration? A prospective study. J Os Articulation Surg Br. 1987;69(five):840–842.

5. Yang KC, Li YT. Handling of recurrent ingrown great toenail associated with granulation tissue by partial nail avulsion followed by matricectomy with sharpulse carbon dioxide laser. Dermatol Surg. 2002;28(5):419–421.

six. Ikard RW. Onychocryptosis. J Am Coll Surg. 1998;187(1):96–102.

seven. Scher RK. Toenail disorders. Clin Dermatol. 1983;i(1):114–124.

8. Rounding C, Bloomfield Due south. Surgical treatments for ingrowing toenails. Cochrane Database Syst Rev. 2005;(2):CD001541.

ix. Aksakal AB, Atahan C, Oztas P, Oruk S. Minimizing postoperative drainage with 20% ferric chloride after chemical matricectomy with phenol. Dermatol Surg. 2001;27(2):158–160.

ten. Ozdemir E, Bostanci S, Ekmekci P, Gurgey E. Chemic matricectomy with 10% sodium hydroxide for treatment of ingrowing toenails. Dermatol Surg. 2004;xxx(1):26–31.

11. Peggs JF. Ingrown toenails. In: Pfenninger JL and Fowler GC. Pfenninger and Fowler's Procedures for Primary Care. 2d ed. St. Louis, Mo.: Mosby;2003:269–272.

12. Daniel CR Iii, Iorizzo 1000, Tosti A, Piraccini BM. Ingrown toenails. Cutis. 2006;78(vi):407–408.

13. Senapati A. Bourgeois outpatient direction of ingrowing toenails. J R Soc Med. 1986;79(6):339–340.

14. Woo SH, Kim IH. Surgical pearl: nail border separation with dental floss for ingrown toenails. J Am Acad Dermatol. 2004;50(6):939–940.

15. Arai H, Arai T, Nakajima H, Haneke E. Formable acrylic handling for ingrowing nail with gutter splint and sculptured nail. Int J Dermatol. 2004;43(10):759–765.

16. Gerritsma-Bleeker CL, Klaase JM, et al. Partial matrix excision or segmental phenolization for ingrowing toe-nails. Curvation Surg. 2002;137(iii):320–325.

17. Zuber TJ. Ingrown toenail removal. Am Fam Md. 2002;65(12):2547–2552, 2554.

18. Monheit GD. Nail surgery. Dermatol Clin. 1985;iii(3):521–530.

xix. Brown FC. Chemocautery of ingrown toenails. J Dermatol Surg Oncol. 1981;seven(4):331–333.

20. Ozawa T, Nose Yard, Harada T, et al. Patrial matricectomy with a CO2 light amplification by stimulated emission of radiation for ingrown toenail after smash matrix staining. Dermatol Surg. 2005;31(3):302–305.

21. Bos AMC, van Tilburg MW, et al. Randomized clinical trial of surgical technique and local antibiotics for ingrowing toenail. Br J Surg. 2007;94(three):292–296.

22. Serour F. Recurrent ingrown big toenails are efficiently treated by CO2 laser. Dermatol Surg. 2002;28(half-dozen):509–512.

23. Siegle RJ, Stewart R. Recalcitrant ingrown nails. Surgical approaches. J Dermatol Surg Oncol. 1992;18(8):744–752.

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