Ingrown Toenail

BASICS

DESCRIPTION

In an ingrown toenail, the distal margin of the nail plate grows into the lateral nail fold, causing irritation, inflammation, and sometimes bacterial or fungal infection:
- Stage 1 (inflammation): erythema, edema, tenderness to palpation of lateral nail fold
- Stage 2 (abscess): increased pain, erythema, and edema as well as drainage (purulent or serous)
- Stage 3 (granulation): chronic inflammation leads to further erythema, edema, and pain, often with granulation tissue growing over the nail plate and significant nail fold hypertrophy
Can be recurrent
Synonym(s): onychocryptosis, unguis incarnatus

EPIDEMIOLOGY

Great toenail is most often affected.
Lateral edge of nail is more commonly affected than the medial edge.
Most common in males aged 16 to 25 years
More common in elderly females than in elderly males
More common in those with lower incomes

Prevalence

24.5/1,000 overall
50/1,000 ≥65 years

ETIOLOGY AND PATHOPHYSIOLOGY

Nail plate penetrates the nail fold causing a foreign body reaction (inflammation).
Bacteria or fungi may enter through the opening in the nail fold, causing infection and abscess formation.
The inflamed and infected area leads to granulation tissue and hypertrophy of the nail fold.

RISK FACTORS

Genetic factors
- Increased nail fold width
- Decreased nail thickness
- Medial rotation of the toe
Many others proposed; none proven, including the following:
- Distorted, thickened nail (onychogryphosis)
- Fungal infection (onychomycosis)
- Hyperhidrosis
- Improper trimming of the lateral nail plate
- Poorly fitting shoes
- Trauma to nail or nail fold
- Conditions that predispose to pedal edema (i.e., thyroid dysfunction, diabetes, obesity, heart failure, renal disease)

GENERAL PREVENTION

Properly fitting shoes
Proper nail trimming (see "Patient Education")

DIAGNOSIS

HISTORY

Pain
Redness
Swelling
Drainage

PHYSICAL EXAM

Nail fold tenderness
Erythema
Edema
Drainage (serous or purulent)
Granulation tissue
Lateral nail fold hypertrophy

DIFFERENTIAL DIAGNOSIS

Cellulitis
Felon (pulp abscess on plantar aspect of toe)
Onychogryphosis (gross thickening and hardening of the nail)
Onycholysis (separation of nail from nail bed)
Onychomycosis (fungal infection of the nail)
Osteomyelitis
Paronychia
Subungual exostosis (osteochondroma beneath the nail)

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)
None needed unless patient appears septic. Then consider CBC and blood cultures.

Consider MRI, x-ray, or bone scan if osteomyelitis is suspected.
Consider x-ray if subungual exostosis is suspected.

TREATMENT

Surgical interventions are more effective than nonsurgical interventions in preventing recurrence (1,2)[A].
The use of phenol for nail bed ablation is probably more effective than nail avulsion alone in preventing recurrence (1,2)[A].
Nail avulsion techniques (described in the following section) are more effective than nail fold debulking techniques (not described in this topic) (2)[A].
Nonsurgical interventions, such as a flexible gutter splint, are another option for treatment of stage 2 or 3 ingrown nails (3,4)[B].

GENERAL MEASURES

For stage 1:

Warm, soapy water soaks for 10 to 20 minutes twice daily until symptoms resolve (5)
Proper nail trimming
Properly fitted shoes

MEDICATION

Neither oral nor topical antibiotics are useful as an adjunct to surgical treatment.
NSAIDs are usually adequate for analgesia.

ADDITIONAL THERAPIES

For stage 1 ingrown nails, several treatments are available:
- Cotton wool
  - Bluntly insert a wisp of cotton under the ingrown portion of the nail using a small curette or nail elevator.
  - Instruct the patient to reinsert new cotton if the other comes out until the nail grows beyond the nail fold.
  - Consider adding silver nitrate cautery to the nail fold, which the patient then repeats at home.
- Dental floss
  - Bluntly insert some dental floss to lift the nail away from the lateral nail fold.
  - Instruct the patient to replace the floss as necessary if it comes out or gets dirty.
  - Keep floss in place until the nail grows beyond the nail fold.
- Taping
  - Apply surgical tape to both sides of toe.
  - Use another piece of tape from one side to the other to pull the lateral nail fold away from the nail plate.
  - Instruct the patient to keep taping until the nail grows beyond the fold.
- Cryotherapy of the lateral nail fold
For stage 2 ingrown nails, consider attempting conservative treatment, as above, especially cotton wool, or cryotherapy.

SURGERY/OTHER PROCEDURES

For stage 2 ingrown nails where conservative treatment has failed, stage 3 ingrown nails, or recurrent ingrown nails, consider either
- Partial avulsion of the nail with phenol nail matrix ablation
  - Achieve local anesthesia as described in the following text.
  - May consider placing a tourniquet around the base of the toe to assist with hemostasis (caution in patients with diabetes or peripheral vascular disease)
  - Elevate the ingrown part of the nail from the nail bed with a periosteal (Freer) elevator or hemostat.
  - Incise the nail longitudinally with scissors or a nail splitter a few millimeters from the ingrown border, starting at the distal edge and proceeding to the matrix.
  - Grasp the avulsed fragment with a hemostat and pull this portion gently out with a hemostat, utilizing longitudinal traction, as well as rotation if needing.
  - Remove the tourniquet once hemostasis is attained.
  - Dip a urethral swab in 80-88% phenol solution.
  - Apply the phenol for 1 minute to the nail matrix under the proximal nail fold. Use multiple swabs if necessary.
  - Wash the area with isopropyl (rubbing) alcohol to neutralize phenol.
- Flexible gutter splint
  - Cut a 1- to 2-cm long piece of sterilized plastic tube, such as IV tubing, 2 to 3 mm in diameter (alternatively, you may use a cap from a 29-gauge needle).
  - Make a slit in the tubing lengthwise and cut the end off at an angle.
  - Apply local anesthesia (see below).
  - Release the ingrown edge of the nail from the nail fold with a hemostat.
  - Slide the tube, angled end first, along the ingrown edge of the nail.
  - Consider fixing the tube in place with self-curing formable acrylic resin (used for dentures and sculptured nails), tape, or a single suture through the nail plate.
  - Leave the tube in place until nail has grown beyond the nail fold.
Other options for nail matrix ablation include the following:
- Sodium hydroxide (NaOH)
- Cryotherapy
- Electrocautery with a special flattened tip coated with Teflon on one side to protect the proximal nail fold
- Radiofrequency ablation
- Carbon dioxide laser
- Curettage
- Surgical excision
Local anesthesia can be achieved with either
- Distal wing block: Infuse 1% lidocaine without epinephrine near the junction of the proximal and lateral nail folds. Continue infusing until the nail folds and the tip of the digit under the distal nail are white from the pressure of the anesthetic.
- Digital ring block: Infuse 1% lidocaine without epinephrine on the medial and lateral surfaces of the involved digit to anesthetize the plantar and dorsal digital nerves. Lidocaine with epinephrine may be used in selected patients (no peripheral vascular disease, diabetes, cardiac problems, or any evidence of digital infection, gangrene, or bone fracture) (6).

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Dress with antibiotic ointment or sterile petroleum jelly; cover with sterile gauze and tube gauze.
Postop instructions should include the following:
- Rest and elevate the foot for 12 to 24 hours.
- Take NSAIDs for discomfort.
- Change dressing and wash with soap and water at least daily for 1 to 2 weeks following procedure.
- Expect a sterile exudate for 2 to 6 weeks.
- Avulsed nails may take 6 to 12 months to grow completely out (if no matrix ablation).
- Call for increasing pain, redness, or swelling.
- Average time to return to normal activities is 2 weeks.
Patients treated conservatively should be followed up in the office every 7 to 10 days until marked improvement is noted.

PATIENT EDUCATION

Trim nails straight across perpendicular to long axis of the nail (do not round corners) and not too short.
Wear properly fitting, comfortable shoes.

COMPLICATIONS

Cellulitis after surgical procedure (uncommon)
Damage to fascia or periosteum from overly aggressive matrix ablation
Damage to nail bed
Distal toe ischemia due to prolonged use of a tourniquet during surgery (rare)
Nail plate deformity (due to nail matrix damage)
Osteomyelitis (rare)
Permanent narrowing of nail (if partial matrix ablation is performed)
Persistent postoperative wound drainage
Recurrence (40-80% with avulsion alone, 0.6-14% with matrix ablation, 6-13% with gutter splint)

REFERENCES

11 Eekhof JA, Van Wijk B, Knuistingh Neven A, et al. Interventions for ingrowing toenails. Cochrane Database Syst Rev. 2012;(4):CD001541.22 Park DH, Singh D. The management of ingrowing toenails. BMJ. 2012;344:e2089.33 Arai H, Arai T, Nakajima H, et al. Formable acrylic treatment for ingrowing nail with gutter splint and sculptured nail. Int J Dermatol. 2004;43(10):759-765.44 Nazari S. A simple and practical method in treatment of ingrown nails: splinting by flexible tube. J Eur Acad Dermatol Venereol. 2006;20(10):1302-1306.55 Heidelbaugh J, Lee H. Management of the ingrown toenail. Am Fam Physician. 2009;79(4):303-308.66 Altinyazar HC, Demirel CB, Koca R, et al. Digital block with and without epinephrine during chemical matricectomy with phenol. Dermatol Surg. 2010;36(10):1568-1571.

ADDITIONAL READING

Bos AM, van Tilburg MW, van Sorge AA, et al. Randomized clinical trial of surgical technique and local antibiotics for ingrowing toenail. Br J Surg. 2007;94(3):292-296.
Chapeskie H. Ingrown toenail or overgrown toe skin?: alternative treatment for onychocryptosis. Can Fam Physician. 2008;54(11):1561-1562.
Reyzelman AM, Trombello KA, Vayser DJ, et al. Are antibiotics necessary in the treatment of locally infected ingrown toenails? Arch Fam Med. 2000;9(9):930-932.
Richert B. Basic nail surgery. Dermatol Clin. 2006;24(3):313-322.
Woo SH, Kim IH. Surgical pearl: nail edge separation with dental floss for ingrown toenails. J Am Acad Dermatol. 2004;50(6):939-940.

CODES

ICD10

L60.0 Ingrowing nail

ICD9

703.0 Ingrowing nail

SNOMED

400200009 ingrowing toenail (disorder)
201108001 Ingrowing great toenail
201109009 Ingrowing toenail (excluding great toe)
25055007 Ingrowing nail with infection (disorder)

CLINICAL PEARLS

The best treatment for a stage 1 ingrown toenail is to insert a wisp of cotton or dental floss between the nail plate and lateral nail fold.
The best treatment for a stage 3 ingrown toenail is partial nail avulsion with phenol matrix ablation.
Patients can prevent ingrown toenails by trimming nails properly and wearing properly fitting shoes.
Oral and topical antibiotics are not useful in the treatment of ingrown nails in conjunction with surgical treatment.

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