Onychocryptosis, are a common problem, and causes include poorly fitting (tight) footwear, infection, improperly trimmed toenails, trauma, and heredity. The biggest risk of an ingrown toenail is that it may become infected. An infection can lead to a condition called gangrene, in which tissue dies due to a lack of blood supply. In severe cases, gangrene can even lead to amputation.
Onychocryptosis is a fairly frequent problem resulting from either growth of nail fold inwards into the nail bed or abnormal embedding of the nail plate into the nail groove, causing significant discomfort.
An ingrown toenail (onychocryptosis) is caused by the pressure from the ingrowth of the nail edge into the skin of the toe. Once the edge of the nail breaks through the skin, it produces inflammation.
Current methods of treatment for onychocryptosis with matrixectomy are categorized either as a chemical ablation matrixectomy involving phenol or sodium hydroxide, or excisional matrixectomies which involve “cold steel” removal of the offending nail matrix with or without the nail bed. Most ingrown toenails can be treated by soaking the foot in warm, soapy water and applying a topical antibiotic ointment, such as polymyxin/neomycin (one brand: Neosporin). Your doctor can also put cotton wisps, dental floss, or splints under the edge of the ingrown toenail between the toenail and the skin.
Other Names
- Ingrown Toenail
- Unguis Incarnates
- Onychocryptosis
Pathophysiology
- General
- Characterized by penetration of the periungual dermis by its contiguous nail plate
- Often results in a cascade of foreign body, inflammatory, infectious, and reparative processes
- If untreated, it can cause considerable pain, discomfort, and disability
- Location
- Great toe represents 70% of cases, likely related to increased stress during ambulation
Causes
- Improper nail trimming
- Appears to be the most common etiology
- May lead to a nail spike that traumatizes adjacent soft tissue
- Excess of skin surrounding the nail
- Wide lateral tissue tending to bulge up around the nail leading to pressure and necrosis
- Nail plate edge grows into the overlapping lateral nail fo
- Demographic
- Advanced age
- Caucasian
- Individuals earning less than 100,000
- Residents of southern US
- Systemic
- Diabetes Mellitus
- Obesity
- Hyperhidrosis
- Podiatric
- Improper nail trimming technique[1]
- Trichotillomania
- Trauma[3]
- History of nail surgery
- Constricting footwear
- Bony abnormalities
- Onychomycosis
- Second toe length equal to or greater than their ipsilateral hallux
- Nail dysfunction (controversial)
- Pincer-nail deformity
- Wide nail plates
- Congenital malalignment of the toenails
- Thickening of the nail plate
- Medications
- Epidermal growth factor receptor inhibitors (gefitinib, cetuximab)
- Protease inhibitors (Indinavir, Ritonavir))
- Retinoids
- Docetaxel
- Cyclosporine
- Oral antifungals (name?)
- Protective (reduced risk)
- Barefoot populations[8]
- Fractures & Osseous Disease
- Traumatic/ Acute
- Talus Fracture
- Calcaneus Fracture
- Traumatic Navicular Fracture
- Cuboid Fracture
- Cuneiform Fracture
- Metatarsal Fracture
- Fifth Metatarsal Fracture
- Toe Fracture
- Hallux Sesamoid Fracture
- Stress Fractures
- Navicular Stress Fracture
- Metatarsal Stress Fracture
- Other Osseous
- Tarsal Coalition
- Accessory Navicular Syndrome
- Traumatic/ Acute
- Dislocations & Subluxations
- Toe Dislocation
- Lisfranc Injury
- Chopart Complex Injury
- Cuboid Syndrome
- Muscle and Tendon Injuries
- Posterior Tibial Tendon Dysfunction
- Peroneal Tendonitis
- Tibialis Anterior Tendinopathy
- Flexor Hallucis Longus Tendinopathy
- Ligament Injuries
- Plantar fasciopathy (Plantar Fasciitis)
- Turf Toe
- Plantar Plate Tear
- Spring Ligament Injury
- Neuropathies
- Mortons Neuroma
- Tarsal Tunnel Syndrome
- Joggers Foot (Medial Plantar Nerve)
- Baxters Neuropathy (Lateral Plantar Nerve)
- Arthropathies
- Hallux Rigidus (1st MTPJ OA)
- Gout
- Toenail
- Subungual Hematoma
- Subungual Exostosis
- Nail Bed Laceration
- Onychocryptosis (Ingrown Toenail)
- Onychodystrophy
- Paronychia
- Onychomycosis
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin’s Disease)
- Calcaneal Apophysitis (Sever’s Disease)
- Freibergs Disease (Avascular Necrosis of the Metatarsal Head)
Symptoms
Symptoms of an ingrown nail include pain along the margins of the nail (caused by hyper granulation that occurs around the aforementioned margins), worsening of pain when wearing tight footwear, and sensitivity to pressure of any kind, even the weight of bedsheets. Bumping of an affected toe can produce sharp and even excruciating pain as the tissue is punctured further by the nail. By the very nature of the condition, ingrown nails become easily infected unless special care is taken early to treat the condition by keeping the area clean. Signs of infection include redness and swelling of the area around the nail, drainage of pus and watery discharge tinged with blood. The main symptom is swelling at the base of the nail on the ingrowing side (though it may be both sides).
Onychocryptosis should not be confused with a similar nail disorder, convex nail, nor with other painful conditions such as involuted nails, nor with the presence of small corns, callus or debris down the nail sulci (grooves on either side).
Diagnosis
- History
- Diagnosis is generally straightforward
- Most patients will present with toe pain
- Inquire about chronology, prior trauma, footwear, occupation, sports activities, and hobbies
- Assess pain at rest, standing, and ambulating.
- Physical Exam: Physical Exam Foot
- Nail polish should be removed to facilitate a complete examination
- Nails are also evaluated with the patient upright and during the gait
- Stage 1: signs of inflammation in the affected toe: pain, swelling, and erythema
- Stage 2: acute infection with seropurulent drainage, ulceration of the nail fold, causing more edema and tenderness
- Stage 3: Hypertrophic granulation tissue, increases compression, swelling and discharge
- Special Tests
Radiographs
- Standard Radiographs Foot
- Not necessary to make diagnosis
- Can help identify risk factors, contributing biomechanical dysfunction
- Specifically, useful to exclude benign and malignant growths of the toes
Classification
- Mild (Stage I)
- Nail fold swelling, edema, erythema
- Pain exacerbated by pressure
- Moderate (Stage II)
- Stage I features coupled with an active or acute infection
- Presents as granulation tissue, seropurulent discharge, or ulceration of the nail fold
- Severe (Stage III)
- Chronic inflammation with formation of epithelialized granulation tissue
- Marked nail fold hypertrophy
Treatment
Nonoperative
- Indications
- Stage I disease
- Can attempt in stage II, III but will often require surgery
- Goals
- Relieve symptoms
- Prevent the ingrown toenail from worsening
- Address the underlying problem
- prevent recurrences
- Address underlying etiology
- E.g. systemic disease (diabetes, obesity), local (nail abnormalities, onychomycosis, subungual neoplasms, etc)
- Medications (indinavir, ritonavir, retinoids, docetaxel, cyclosporine, and oral antifungals)
- Suitable footwear
- Encourage the use of “wide toe box” or “open toe” shoes
- Avoid high heeled or pointy shoes that are too narrow
- Suitable support (cushioning, laces) to prevent feet sliding forward and being compressed by the front of the shoe
- Taping
- Goal: separate the nail fold from the offending nail edge[9]
- Basic: daily application pulling the offending nail fold away from the nail plate in oblique and proximal directions
- Additional securing: consider cyanoacrylate adhesive, acetone, mastisol, and a second anchoring tape
- Cotton Packing
- Daily home insertion of a cotton wisp, sometimes soaked with antiseptic, between the corner of the nail plate and the nail fold
- Over time, more cotton is inserted until sufficient separation is achieved to mitigate symptoms[10]
- Alternative: “rolled cotton padding” or “cotton-nail cast” with cyanoacrylate can be applied in the office, left in place for up to 2 months
- Efficacious in treating stage I, II, and III patients[11]
- Gutter Packing
- Description: use of a sterile plastic tube (from IV drip, butterfly needle) with a vertical slit that is inserted into the nail groove
- One study using acrylic resin (N=106) had a 100% cure rate, even for more severe stages[12]
- Proper nail cutting technique education
- Counsel patient to trim toenails by cutting straight across the nail plate without rounding the edges
- Incorrectly rounding off the nail plate corners promotes barbs or spicules that may anchor into the periungual soft tissue
- Orthonyxia
- Nail correction is performed to rectify nail overcurvature using a nail brace or elastic wiring
- One study found that compared partial matrix excision, resulted in significant improvement<Kruijff S, van Det RJ, van der Meer GT, et al. Partial matrix excision or orthonyxia for ingrowing toenails. J Am Coll Surg. 2008;206:148- 53. [PMID: 18155581].</ref>
- Warm soaks
- Soaks for 10 to 20 minutes daily in warm, soapy water often provide symptomatic relief.
- Hydrogen peroxide and iodine can be used for cleaning
- Topical medications
- Generally considered controversial, clinical trial data is lacking
- Antibiotics and steroids are suggested in some of the literature
- Silver nitrate may decrease inflammation and expedite healing
- Custom Orthotics
- Podiatry Referral
Operative
- Indications
- Failure of conservative management, especially in stage II or III
- Recurrence
- Significant infection
- Technique
- Partial nail avulsion
- Matricectomy
- Vandenbos procedure
- Zadik technique
- Winograd procedure
