Ingrown toenail, also known as onychocryptosis or uunguisincarnatus, is the most common nail problem encountered in both general practice and dermatology.[rx]
An ingrown toenail occurs when the nail plate grows into the periungual skin and causes infection, or irritation, often causing pain, swelling, heat, or redness. সহজ বাংলা: শরীরের প্রদাহ; ব্যথা, ফোলা বা লালভাব হতে পারে।" data-rx-term="inflammation" data-rx-definition="Inflammation is the body’s response to injury, infection, or irritation, often causing pain, swelling, heat, or redness. সহজ বাংলা: শরীরের প্রদাহ; ব্যথা, ফোলা বা লালভাব হতে পারে।">inflammation and infection. It causes considerable pain, discomfort, and disability if left untreated. An ingrown toenail may present at any age, but it affects most commonly teenagers and young adults. The hallux nails are the most frequent location.[rx]
Management options range from conservative treatments to extensive surgical approaches, depending on the severity and the stage of the condition.
Causes
Improper nail trimming appears to be the most common etiology of ingrown toenails as it may lead to a nail spike that traumatizes adjacent soft tissue.[2][3] Other predisposing factors for ingrown toenails include tight-fitting shoes, bad foot hygiene, hyperhidrosis, trauma, and the use of some medications, especially epidermal growth factor receptor inhibitors (gefitinib, cetuximab).
The possible involvement of intrinsic risk factors in the pathogenesis of ingrown toenails, such as abnormal nail shape and anatomical abnormalities, has been widely debated. Some studies have found that pincer-nail deformity, wide nail plates, congenital malalignment of the toenails, and thickening of the nail plate represent possible risk factors for ingrown toenails.[3][4]
Other studies proved that bone abnormalities that increase the internal pressure, in the ankle, foot, or toe, might play a role in the development of ingrown toenails.[1][5] However, more recent reports suggest no difference in anatomical abnormalities between patients with ingrown toenails and controls.[6]
Pathophysiology
Many theories have been proposed to explain the onset of ingrown toenails. One assumption is that it is related to the excess skin surrounding the nail, which is the real culprit. It is explained by wide lateral tissue tending to bulge up around the nail leading to pressure and necrosis.[8] However, the most accepted theory is that ingrown toenail occurs when the nail plate edge grows into the overlapping lateral nail fold, causing painful infection, or irritation, often causing pain, swelling, heat, or redness. সহজ বাংলা: শরীরের প্রদাহ; ব্যথা, ফোলা বা লালভাব হতে পারে।" data-rx-term="inflammation" data-rx-definition="Inflammation is the body’s response to injury, infection, or irritation, often causing pain, swelling, heat, or redness. সহজ বাংলা: শরীরের প্রদাহ; ব্যথা, ফোলা বা লালভাব হতে পারে।">inflammation and leading to the formation of granulation tissue.[7][8] Reactive ground forces due to obesity and/or constricting footwear aid this penetration.[2]
History and Physical
An ingrown toenail is a straightforward diagnosis. Almost all the patients present with toe pain. This pain may be responsible for different levels of discomfort and disability, ranging from a simple difficulty with walking, to a complete inability to ambulate.[7] Physical examination findings may vary depending on the stage of the disease.
The initial presentation, corresponding to stage 1, is characterized by signs of infection, or irritation, often causing pain, swelling, heat, or redness. সহজ বাংলা: শরীরের প্রদাহ; ব্যথা, ফোলা বা লালভাব হতে পারে।" data-rx-term="inflammation" data-rx-definition="Inflammation is the body’s response to injury, infection, or irritation, often causing pain, swelling, heat, or redness. সহজ বাংলা: শরীরের প্রদাহ; ব্যথা, ফোলা বা লালভাব হতে পারে।">inflammation in the affected toe: pain, swelling, and allergy, infection, or inflammation. সহজ বাংলা: চামড়া লাল হয়ে যাওয়া।" data-rx-term="erythema" data-rx-definition="Erythema means skin redness, often from irritation, allergy, infection, or inflammation. সহজ বাংলা: চামড়া লাল হয়ে যাওয়া।">erythema. The initial stage is followed by an acute infection with seropurulent drainage and ulceration of the nail fold, causing more edema and tenderness (stage 2). Chronic infection leads then to the formation of a hypertrophic granulation tissue, which increases the compression and thus adds to the swelling and discharge (stage 3).[rx][]rx
Evaluation
The diagnosis of an ingrown toenail is classically based on clinical features and does not require any laboratory or radiographic tests.
If physical examination reveals a subungual nodule, an X-ray examination may be needed to rule out subungual exostosis. In such cases, it reveals a subungual bony proliferation.
Treatment
Treatment methods for ingrown toenails range from medical measures to surgical interventions. Indications for the treatment depend mainly on the stage of the condition, prior modalities of treatment in case of recurrence, and other factors including allergies to local anesthetics, pregnancy, and bleeding disorders. Conservative measures are generally recommended in cases of mild to moderate lesions (stages 1 and 2), whereas severe lesions causing disability to require surgical methods (stage 3).[rx][tc][rx][rx]
General Measures
General measures for ingrown toenails include proper footwear as well as correct nail trimming; this includes avoiding curved cutting off the lateral margins of the nail plate. General measures should also include management of the underlying factors (hyperhidrosis, onychomycosis). Soaking the affected toe in warm soapy water for several minutes, followed by the application of a topical bacterial infections. সহজ বাংলা: ব্যাকটেরিয়ার সংক্রমণের ওষুধ।" data-rx-term="antibiotic" data-rx-definition="An antibiotic is a medicine used to treat bacterial infections. সহজ বাংলা: ব্যাকটেরিয়ার সংক্রমণের ওষুধ।">antibiotic ointment may give relief. The application of topical steroids to the hypertrophic granulation tissue may decrease infection, or irritation, often causing pain, swelling, heat, or redness. সহজ বাংলা: শরীরের প্রদাহ; ব্যথা, ফোলা বা লালভাব হতে পারে।" data-rx-term="inflammation" data-rx-definition="Inflammation is the body’s response to injury, infection, or irritation, often causing pain, swelling, heat, or redness. সহজ বাংলা: শরীরের প্রদাহ; ব্যথা, ফোলা বা লালভাব হতে পারে।">inflammation.[rx][1rx
Conservative Techniques
- Cotton-wick insertion under the corner of the nail: Cotton wisp or pledget are placed under the ingrown lateral groove corner using a nail elevator.
- Dental floss technique: This is an alternative to the cotton wisps. A string of dental floss is inserted under the ingrown nail to separate it from the lateral fold.
- The gutter splint or sleeve technique: Gutter strips are prepared by cutting to size vinyl intravenous infusion tube from top to bottom. The lateral edge of the nail plate gets splinted with this sterilized splint plastic tube and then attached with adhesive tape or strips, giving instant relief of pain.
- Taping procedure: One end of the tape gets placed against the side of the ingrown toenail, with the rest twisted around the toe. The aim is to pull the side of the nail fold away from the nail to decrease pressure. Taping is the safest and least painful procedure among conservative options.
- Nail wiring: Two holes are made at the distal edge of the nail, and an elastic wire is inserted and bent forward. The elasticity of the wire may correct the deformity of the ingrown toenail.
Surgical Techniques
Surgical procedures for ingrown toenails are performed under local anesthesia (LA). There are various techniques for LA, including digital block, metatarsal block, or transthecal anesthesia… Any local anesthetic can be used (lidocaine, ropivacaine, mepivacaine, or prilocaine) in 1 to 2% concentrations. Indications for LA depend mainly on the type of surgery and the physician’s preference.
Surgical options for ingrown toenails are:
- Spicule excision and partial mastoidectomy: It consists of excising the affected portion of the nail with a partial mechanical mastoidectomy.
- Chemical partial mastoidectomy: Chemical mastoidectomy is commonly performed using phenol. It demonstrates a higher success rate and is less painful than mechanical mastoidectomy. Its success depends on good hemostasis. Other chemical agents can be employed, such as sodium hydroxide and trichloroacetic acid.
- Wedge resection of the toenail and nail fold: This approach consists of the excision of the affected portion of the nail plate, partial mastoidectomy, and wedge dissection of the nail bed and the hypertrophic nail fold. Clinicians should generally avoid this technique.
- Excision of the affected nail and total mastoidectomy: It is a more radical solution to ingrown toenails, consisting of excision of the affected nail, nail bed, and a total mastoidectomy (chemical or mechanical). It is indicated for stage IV ingrown toenails, for onychogryphosis, and onychodystrophy.
- Soft-tissue nail fold excision technique: This procedure does not touch the nail as its basis is the theory that the nail is not the causative factor in the development of ingrown toenails. It consists of wide excision of the soft tissue enveloping in an elliptical manner.
Thus, surgical treatment options for ingrown toenails are numerous, and there is no consensus on the technique of choice. The ideal procedure should lead to the best functional and aesthetic outcome, as well as a low rate of recurrence. Many studies have proven that simple nail avulsions lead to high recurrence rates, while phenol mastoidectomy has shown greater success.
