Ingrown Toenail Treatment

An occurs when the nail plate grows into the periungual skin and causes 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.

An ingrown toenail is also known as onychocryptosis or unguis incarnatus, a common nail problem occurring when the nail plate grows into the periungual skin and causes inflammation and infection. It causes considerable pain, discomfort, and disability if left untreated.

Doctors distinguish between three stages of severity:

• Stage 1: The nail has grown into the skin on the side. The skin hurts and has become inflamed.
• Stage 2: New, inflamed tissue (granuloma) has grown at the edges of the ingrown toenail. The tissue is weeping and producing pus.
• Stage 3: The skin around the toenail is chronically inflamed and keeps oozing pus. The granuloma has already started growing over the nail.

Symptoms

Ingrown toenail symptoms include:

• Pain and tenderness
• Inflamed skin
• Swelling
• Infection
• Ingrown toenails cause the affected skin to become inflamed. The blood supply to that part of the toe increases, and it becomes red, swollen and painful.
• Sometimes new tissue starts growing over the toenail. Doctors call this a granuloma because the surface of the new tissue looks a bit like tiny granules. The inflamed area may weep, bleed or release pus and have an unpleasant odor – especially if bacteria get into the wound.
• The symptoms are caused when the edge of the toenail presses into the skin and continues to grow. If this edge injures the skin and the soft tissue underneath it, inflammation will occur.

Diagnosis

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 inflammation in the affected toe: pain, swelling, and 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]

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][rx][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 antibiotic ointment may give relief. The application of topical steroids to the hypertrophic granulation tissue may decrease inflammation.[rx][rx]

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.

• Others: slit tape-strap procedure, acrylic nails, nail braces.[7rx[rx][rx]

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.

• Other techniques: Newer techniques, including electrocautery, radiofrequency ablation, and carbon dioxide laser ablation, have become the newest form of ingrown toenail management.[3][8][14]

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.

Home Remedies

If home remedies haven’t helped your ingrown toenail, your health care provider may recommend:

• Lifting the nail. For a slightly ingrown nail, your health care provider may carefully lift the ingrowing nail edge and place cotton, dental floss, or a splint under it. This separates the nail from the overlying skin and helps the nail grow above the skin edge, usually in 2 to 12 weeks. At home, you’ll need to soak the toe and replace the material daily. Your health care provider might also prescribe a corticosteroid cream to apply after soaking. Another approach, which minimizes the need for daily replacement, uses cotton coated with a solution that fixes it in place and makes it waterproof (collodion).
• Taping the nail. With this method, your health care provider pulls the skin away from the ingrown nail with tape.
• Placing a gutter splint under the nail. With this method, your health care provider numbs the toe and slips a tiny slit tube underneath the embedded nail. This splint stays placed until the nail has grown above the skin edge. This method helps ease the pain of an ingrown nail as well.
• Partially removing the nail. For a more severe ingrown toenail (inflamed skin, pain, and pus), your health care provider may numb the toe and trim or remove the ingrown portion of the nail. It could take 2 to 4 months for your toenail to grow back.
• Removing the nail and tissue. If you have the problem repeatedly on the same toe, your health care provider may suggest removing a portion of the nail along with the underlying tissue (nail bed). This procedure may prevent that part of the nail from growing back. Your health care provider will numb the toe and use a chemical, a laser, or other methods.

After a nail-removal procedure, you can take a pain reliever as needed. It might help to apply a wet compress for a few minutes for a few days until the swelling has gone down. And rest and elevate the toe for 12 to 24 hours. When you resume moving about, avoid activities that hurt your toe, and don’t swim or use a hot tub until your health care provider tells you it’s okay. It’s okay to shower the day after surgery. Call your health care provider if the toe isn’t healing.

Sometimes, even with successful surgery, the problem occurs again. Surgical approaches are better at preventing recurrence than are nonsurgical methods.

Lifestyle and home remedies

You can treat most ingrown toenails at home. Here’s how:

• Soak your feet in warm, soapy water. Do this for 10 to 20 minutes 3 to 4 times a day until the toe improves.
• Place cotton or dental floss under your toenail. After each soaking, put fresh bits of cotton or waxed dental floss under the ingrown edge. This will help the nail grow above the skin’s edge.
• Apply petroleum jelly. Put petroleum jelly (Vaseline) on the tender area and bandage the toe.
• Choose sensible footwear. Consider wearing open-toed shoes or sandals until your toe feels better.
• Take pain relievers. A nonprescription pain reliever such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others) may help ease the toe pain.