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Pincer Nails: Definition and Surgical Treatment

R. Baran, MD*, E. Haneke, MD †, and B. Richert, MD ‡
*Nail Disease Center, Cannes, France, †Klinikk Bunaes, Oslo, Norway, and
‡Department of Dermatology, University Hospital, Liege, Belgium

background. There are four main types of ingrown nail.
These are distal nail embedding, juvenile (subcutaneous) ingrown nail, hypertrophy of the lateral nail fold (lip), and pincer
nail.
objective. The etiology of pincer nail may be hereditary or acquired. The mechanism of the most common form, an enlarged
base of the distal bony phalanx, is discussed.

methods. Use of roentgenogram and magnetic resonance imaging highlights exophytes of the base and dorsal hyperostosis
of the distal phalanx.
results. Global assessment may lead in mild cases to medical
therapy. Usually, however, the lateral matrix horn must be surgically removed or cauterized by phenol. Dermal grafting under
the nail matrix provides excellent long-term results.

TRANSVERSE OVERCURVATURE, progressively
pinching the nail bed distally, is usually called pincer
nail. The curvature commonly increases from proximal to distal, giving it a trumpet-like appearance. The
condition is quite frequent on toes, but rare on fingers.
Other names for this condition include incurved nail,
unguis constringens, transverse overcurvature, trumpet nail, convoluted nail, omega nail.

oid pseudocyst4 may lead to pincer nails, a condition
reversible after treatment of the cause.
Tinea ungium due to Trichophyton rubrum, affecting
equally the great toenail and thumb nail, has been shown
to be responsible for pincer nails.5 The nails gradually
return to normal after systemic antifungal treatment.
Pincer nail deformity may occur after placement of
an arteriovenous fistula (AVF)6 in the forearm. The
nail changes are then restricted to the index and little
fingers. This potential and long-lasting adverse effect
of circulatory disturbance and/or venous hypertension
from AVF for hemodialysis is relatively common and
should be recognized as a specific sign of circulatory
disturbance caused by the AVF.
Pincer nails have been reported after some !-blockers such as practolol7 and acebutolol.8 Transverse
overcurvature of the nails is reversible after discontinuation of the drug.
Pronounced pincer nails have developed in association with a metastasing adenocarcinoma of the sigmoid colon. They are considered as a marker of gastrointestinal malignancy.9
Acquired pincer nail deformity in an infant with
Kawasaki’s disease affected all digits of the hands and
to a lesser extent, the toes. Given the absence of pain,
the nails were left undisturbed and the overcurvature
spontaneously resolved as the nails grew out.10
The most frequent cause of acquired pincer nails is
deformity in the foot with deviation of the phalanges,
probably as a result of ill-fitting shoes.11 Acquired pincer nails of the fingers are commonly seen in degenerative osteoarthritis of the distal interphalangeal joints.

Etiology
There are several different variants of pincer nails,
both hereditary and acquired.1 The hereditary pincer
nail is almost always symmetrical2 (Figure 1). Similar
nail changes may be seen in other family members.
The great toes are usually affected but the smaller toes
may also be involved. The great toe commonly shows
a lateral deviation of the long axis of the distal phalanx, but the overcurved nails are deviated even more
laterally. When the lesser toes are involved they exhibit a medial deviation. This anomaly is already seen
in adolescents and young adults. Of interest, epidermolysis bullosa simplex (Dowling–Meara type)3 may
be associated with pincer nail abnormality, with slight
thickening in both finger and toenails.
Acquired pincer nails are not symmetrical, though
fingernail involvement may be extensive and appear to
be fairly symmetrical. Acquired pincer nails may be
due to a number of different dermatoses, of which
psoriasis is the most frequent. Tumors of the nail apparatus such as exostosis, implantation cyst, or myxR. Baran, MD, E. Haneke, MD, and B. Richert, MD have indicated
no significant interest with commercial supporters.
Address correspondence and reprint requests to: R. Baran, MD, Nail
Disease Centre, 42 rue des Serbes, 06400 Cannes, France, or e-mail
baranrmd@cote-dazur.com.

Pathophysiology
The overcurvature is most probably due to an enlarged base of the distal phalanx to which the matrix

© 2001 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Science, Inc.
ISSN: 1076-0512/01/$15.00/0 • Dermatol Surg 2001;27:261–266

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Figure 2. Enlarged base of the distal phalanx in pincer nail.

Figure 1. Hereditary pincer nails: A) front view, B) symmetrical
dorsal view.

is firmly bound by ligament-like collagen fibers (Figure 2). Since toenails are markedly curved, the curvature of the proximal (matricial) nail plate portion will
decrease and consequently the curvature will increase
distally (Figure 3).
Radiographs and magnetic resonance imaging (MRI)
of big toes with pincer nails invariably show an enlargement of the base of the distal phalanx and often
hooklike lateral osteophytes pointing distally (Figure
4A). This is virtually always more pronounced on the
medial aspect, explaining why the nail’s longitudinal
axis is deviated more laterally than that of the distal
phalanx. The distally more pronounced overcurvature
exerts traction on the nail bed which is transduced to
the bone by the ligament-like fibers fixing the solehorn
to the tip of the terminal phalanx. This eventually results in a traction osteophyte which is also often seen
on radiographs1,12 and MRI (Figure 4B).

the lateral nail plate edges dig into the lateral grooves
and upon further incurving start to pinch the nail bed
(Figure 5). After a while, the soft tissue may actually
disappear and may even be accompanied by resorption of the underlying bone.13
Morphologically there are three clinical types: the
“common” pincer nail (trumpet nail deformity), the
tile-shaped nail, and the plicated nail. The most frequently seen type is the trumpet nail deformity with
the overcurvature increasing along the axis from proximal to distal.14 The lateral plate margins virtually roll
in, sometimes even forming a tube (Figure 6). The nail
bed becomes pinched, shrinks in its transverse diameter, and is lifted up distally by the continuous traction
exerted on the distal dorsal tuft. The lateral plate margins may eventually break through the epidermis and
produce granulation tissue mimicking an ingrown toenail. Cutting the nail may become more and more difficult and painful with increasing overcurvature; furthermore this is frequently associated with thickening
of the nail plate. To enhance the cosmetic appearance,
patients and podiatrists tend to round the distal margin of the overcurved nail plate; this reduces pressure
on the most distal portion of the lateral nail grooves,

Signs and Symptoms
The toenails present a physiologically transverse convexity that is more pronounced than in the fingernails.
When this transverse curvature becomes exaggerated,

Figure 3. The curvature of the proximal nail plate segment decreases and consequently increases distally.

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Figure 6. Trumpet nail.

Figure 4. MRI showing A) lateral osteophyte at the base of the
phalanx and B) distal traction osteophyte.

however, there is a great risk of leaving a nail spike
which inevitably will pierce into the soft tissue.
Pachyonychia congenita may mimick pincer nails, but
it is usually not painful and involves both finger and toenails. Pain is not a consistent symptom of pincer nails.
Some extreme cases are completely painless, whereas
sometimes even mild cases may cause excruciating pain,
provoked by no more than the weight of a bed sheet.14

Figure 5. Pincer nail, a moderate case.

Tile-shaped nails are characterized by an even,
transverse overcurvature with the lateral nail edges remaining parallel. This type is usually less severe, does
not cause serious symptoms, and is frequently seen in
tall young people with the “unguis incarnatus syndrome”15 or in fingernail overcurvature.
The plicated nail presents a moderate convexity
with one (Figure 7) or both lateral plate edges being
sharply bent to form a vertical sheet pressing into the
lateral nail groove. Bilateral symmetrical involvement
of the nails is mainly seen on fingers, but unilateral angling of a nail is common in foot deformities.

Indications for Treatment
The major indications for treatment are pain and inflammation. Other indications are interference with
wearing shoes and cosmetic embarrassment. Therapeutic approaches vary according to the severity and

Figure 7. A) Unilateral nail plication. B) After surgical excision of
the lateral matrix horn.

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baran et al.: pincer nails: definition and surgical treatment

type of overcurvature, possible risk factors, previous
unsuccessful treatment, and a multitude of personal
and psychological preferences of both the treating
physician and patient.
Conservative Treatment

Most patients consulting a physician have already
tried some conservative treatment. Usually they try to
clip down the lateral edge of the incurved nail as far as
possible proximally and they only stop when they cut
into the skin of the lateral nail groove. Since the nail is
frequently thick and hard, it should first be softened
using an emollient under occlusion for some days or a
10-minute hot foot bath prior to nail clipping.
In early overcurvature, thinning of the central portion of the nail plate from the lunula to the free margin may alleviate the pain, since this technique increases the nail plate’s pliability. A single groove or a
series of grooves may be cut into the nail plate surface
using a burr, or the entire nail plate is ground to thin
it. Recently the use of 40% urea paste and subsequent
removal of the softened nail material, performed regularly over a period of 1 year, was shown to normalize
hereditary pincer nails in a 38-year-old woman.16
There are several alternative methods for mechanical
correction of malformed nails, called orthonyx.17–19
The principle is to exert tension on the transverse nail
curvature in order to gradually flatten the plate. After
cleaning the lateral nail grooves, a stainless steel brace
is inserted on the nail plate and fixed under the lateral
edges. An adjustment is made to the brace in order to
exert countertension on the plate, and with a series of
adjustments the nail plate gradually flattens over a period of 6 or more months. We have obtained good responses in treating fingernail overcurvature associated
with osteoarthritis; however, immediate relapse was
observed after orthonyx treatment. More recently,
elastic plastic braces glued to the abraded nail surface
were successfully used by Effendy et al.20
Conservative treatment always appears to be tempting to patients. However, no publication recommending clipping, grooving, thinning, and orthonyx with
steel or plastic braces has mentioned the bone alterations seen in nearly all patients on X-ray films. The
patients we saw all experienced recurrences, usually in
only about half the time needed to correct the pincer
nail. We therefore believe that conservative treatment
of pincer nails gives only some temporary relief.
Surgical Treatment

Repeated nail avulsions21 were thought to permit the
pinched nail bed tissue to flatten spontaneously during
the period of nail plate regrowth. However, many pa-

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tients experience a dramatic worsening of their condition after nail avulsion, and it has been found that
there is rarely any benefit from this procedure. Furthermore, nail avulsion is known to increase the physiological transverse curvature of normal hallux nails.22,23
There is a technique aimed at correcting the firm
swelling of the distal nail bed. The nail bed is cut by a
median longitudinal incision and the soft tissues are
dissected from the terminal phalanx. Reversed tie-over
sutures are put in the lateral nail folds and tied over a
pad on the plantar aspect of the toe in order to spread
the nail bed. The resulting triangular defect is covered
with a free skin graft. The stitches are removed after
about 3 weeks. An onycholytic area will develop corresponding to the size of the free graft.24 This technique was slightly modified by primarily suturing the
nail bed and inserting a small plastic plate between the
curved nail plate and the flattened resutured nail
bed,12 however, the result was not permanent.
In fact, these surgical techniques do not take into
account the underlying bone alterations which cause
the overcurvature. Except for permanent nail eradication14
by surgical nail ablation or phenolization, relapses are frequent.
Judged from the presumed pathogenesis of pincer
nails, it was felt that either the lateral osteophytes or
the matrix horns which are pushed outward and forward by these bony excrescences would have to be removed. Removal of the lateral osteophytes is the procedure thought to offer the best chance of flattering
the nail bed, but it would result in damage to the lateral ligaments of the distal interphalangeal joint. Therefore the permanent removal of the lateral matrix horns
was considered to be the simplest, least painful, but
nevertheless a sufficiently effective treatment modality. (Figure 8). In some cases it may be supplemented
by laterally expanding the pinched nail bed and cutting the distal dorsal bony tuft, if this abnormality is
prominent and associated with pain in the tissue, just
beneath the midportion of the distal nail plate.1,12,25–27
Under regional block anesthesia, lateral nail strips
of the entire nail plate are avulsed. The digit is exsanguinated and the matrix horns are dried and either
carefully dissected and removed, or phenolized by vigorously rubbing in liquefied (90%) phenol for 3 minutes. Small antibiotic tablets are inserted into the
wound cavities. In Haneke’s technique (Figure 9) this
treatment is followed by a median incision of the nail
bed from the lunula border to 2 mm beyond the hyponychium and carried down to the bone. During this
incision, the traction osteophyte is felt with the scalpel
even when it was not obvious on the roentgenogram.
The pinched nail bed is then dissected from the terminal phalanx, the distal dosal tuft with the osteophyte
is rongeured off, and the nail bed is expanded and su-

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baran et al.: pincer nails: definition and surgical treatment

265

Figure 8. A) Pincer nail of a thumb before
treatment. B) The same digit after phenol cautery of the lateral matrix horns.

tured using 6-0 monofil absorbable sutures (PDS II).
Reverse tie-over sutures are placed in the lateral nail
folds, with small rubber tubes being used as a cushion
to prevent the sutures from cutting through the nail
folds. These sutures keep the nail bed stretched over
the bone and are removed after about 3 weeks. In more
than 50 patients, a success rate of more than 80% was
achieved with this technique.
Zook’s team28,29 has suggested another effective procedure which may offer the best chance of flattening the
nail bed. It is important not only to flatten the sterile
matrix (nail bed) but also to flatten the lateral portions of the germinal matrix. Uniformly good results
were obtained with this in relief of pain and improvement of appearance.
In his technique, successful treatment of pincer nail
involves removing the tubed nail to visualize the nail
bed. The paronychium is freed from the periosteum of
the distal phalanx through an incision on the tip at the
distal end of the paronychium. Fine scissors are used to
free the paronychium from the periosteum proximally
to beyond the nail fold, allowing the nail bed to flatten.
A strip of dermis of adequate volume (at least 1 cm in
width) is then pulled beneath the paronychium.
In conclusion, mild cases of pincer nail may sometimes benefit from conservative treatment, but usually
chemical or surgical removal of the lateral matrix
horns, or dermal grafting under the nail matrix provide excellent long-term treatment.
Figure 9. Haneke’s procedure. A) The nail plate (1) is shortened,
showing the pinched nail bed (2). Bilateral cautery of the lateral matrix horns (3) will narrow the nail plate. A longitudinal median incision in the nail bed is carried down to the bone. B) The dorsal tuft of
the phalanx is removed with a bone rongeur. The nail bed is sutured
and then expanded using reversed tie-over sutures placed in the
folds and tied over the plantar aspect of the toe. A frontal view C)
before and D) after treatment. Replacing the original nail with a donor “nail bank transplant” will avoid keratinization of the nail bed.

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