Chapter 200 - Ingrown Toenail

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The Color Atlas and Synopsis of Family Medicine, 3e
Chapter 200: Ingrown Toenail
E.J. Mayeaux, Jr.
PATIENT STORY
A 14yearold boy presents with a history of multiple ingrown nails of both great toes. Today his right big toe is swollen and painful (Figure 2001). He
has a 2week history of pain, redness, and swelling of the lateral nail fold of the right great toe. Soaking the toe in Epsom salts has not helped. A partial
nail removal after a digital block was successful. The nail matrix was also ablated with phenol to prevent recurrence of the ingrown nail.
FIGURE 2001
Ingrown toenail of the lateral aspect of the right great toe showing inflammation and granulation tissue. (Reproduced with permission from Richard P.
Usatine, MD.)
INTRODUCTION
Onychocryptosis (ingrown toenails) is a common childhood and adult problem. Patients often seek treatment because of the significant levels of
discomfort and disability associated with the condition.
SYNONYMS
Onychocryptosis, unguis incarnatus.
EPIDEMIOLOGY
The prevalence of onychocryptosis is unknown, as many patients do not seek medical care and it is not a reportable disease. The toenails, especially
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the great toenail, are most commonly affected. Ingrown toenails at birth and in early childhood do occur, but are very rare.
Chapter 200: Ingrown Toenail, E.J. Mayeaux, Jr. Page 1 / 7
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ETIOLOGY AND PATHOPHYSIOLOGY
Onychocryptosis, unguis incarnatus. Universidad de Monterrey
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EPIDEMIOLOGY
The prevalence of onychocryptosis is unknown, as many patients do not seek medical care and it is not a reportable disease. The toenails, especially
the great toenail, are most commonly affected. Ingrown toenails at birth and in early childhood do occur, but are very rare.
ETIOLOGY AND PATHOPHYSIOLOGY
Onychocryptosis occurs when the lateral nail plate damages the lateral nail fold. The lateral edge of the nail plate penetrates and perforates the
adjacent nailfold skin. Perforation of the lateral fold skin results in painful inflammation that manifests clinically as mild edema, erythema, and pain. In
advanced stages, drainage, infection, and ulceration may be present. Hypertrophy of the lateral nail wall occurs, and granulation tissue forms over the
nail plate and the nailfold during healing of the ulcerated skin.1 It is a common affliction that can result from a variety of conditions that cause
improper fit of the nail plate in the lateral nail groove (see Figure 2001).
RISK FACTORS
Genetic predisposition1.
Poorfitting footwear.
Excessive trimming of the lateral nail plate.
Pincer nail deformity (Figure 2002).
Trauma.
Sports in which kicking or running is important.
Hyperhidrosis.
Anatomic features such as nailfold width.
Congenital malalignment of the digit.
Overcurvature of the nail plate.
Onychomycosis and other diseases that result in abnormal changes in the nail plate.
FIGURE 2002
The curved infolding of the lateral edges of the nail plate indicates that this patient has a pincer nail, which predisposes to onychocryptosis.
(Reproduced with permission from Richard P. Usatine, MD.)
DIAGNOSIS
FIGURE 2002
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The curved infolding of the lateral edges of the nail plate indicates that this patient has a pincer nail, which predisposes to onychocryptosis.
DIAGNOSIS
CLINICAL FEATURES: HISTORY AND PHYSICAL
The diagnosis is based on clinical appearance and rarely is difficult. Characteristic signs and symptoms include pain, edema, exudate, and granulation
tissue (see Figure 2001).
TYPICAL DISTRIBUTION
The great toe is most commonly affected; fingers are rarely involved except when nail biting is present.
DIFFERENTIAL DIAGNOSIS
Cellulitis—Presents with redness, pain, and swelling beyond the nail fold (see Chapter 126, Cellulitis).
Paronychia—Presents with redness and abscess formation (pus) in a nail fold (see Chapter 202, Paronychia).
MANAGEMENT
The treatment of ingrown toenails depends on the age of the patient and the severity of the lesion.
NONPHARMACOLOGIC
Lesions characterized by minimal to moderate pain and no discharge can be treated conservatively with soaking the affected foot in warm water
for 20 minutes, 3 times per day, and pushing the lateral nailfold away from the nail plate.2 S O RⒸ
Other palliative measures include cotton wedging underneath the lateral nail plate and trimming the lateral part of the nail plate below the
area of nailfold irritation.
Gutter treatment (gutter removal or gutter splinting) involves placing a small vinyl or plastic tube that is slit from top to bottom over the side of the
ingrowing plate and affixing it with tape or sutures. This separates the nail plate from the nailfold wall, preventing it from growing further into the
skin.3,4 S O RⒷ
Orthonyxia or brace treatment involves hooking a small metal brace around both edges of the nail plate after the painful part of the nail is
removed. The metal brace has an omega shape that puts the brace under tension when it is attached to the nail plate with gel. This relieves nail
pressure on the fold soft tissue. S O RⒷ Devices that have shown promise include shape memory alloys (SMAs), of either a CuAlMn base or a Ni
Ti base.35
The tape or adhesive bandage method involves placing the adhesive band on the affected fold and pulling it under and the across the toe to
Gutter treatment (gutter removal or gutter splinting) involves placing a small vinyl or plastic tube that is slit from top to bottom over the side of the
ingrowing plate and affixing it with tape or sutures. This separates the nail plate from the nailfold wall, preventing it from growing further into the
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skin.3,4 S O RⒷ
Orthonyxia or brace treatment involves hooking a small metal brace around both edges of the nail plate after the painful part of the nail is
removed. The metal brace has an omega shape that puts the brace under tension when it is attached to the nail plate with gel. This relieves nail
pressure on the fold soft tissue. S O RⒷ Devices that have shown promise include shape memory alloys (SMAs), of either a CuAlMn base or a Ni
Ti base.35
The tape or adhesive bandage method involves placing the adhesive band on the affected fold and pulling it under and the across the toe to
reduce the pressure of the nail fold and the edge of the nail plate. S O RⒸ
MEDICATIONS
Although many elect to treat apparent infections with oral antibiotics, studies show the use of antibiotics does not decrease healing time or
postprocedure morbidity in otherwise normal patients.6 S O RⒶ
A medium to highpotency topical corticosteroid can be applied after soaking to decrease inflammation but is often unnecessary.
If nail avulsion and/or matrix ablation is used, pain relievers for mild to moderate pain may be necessary.
When placing digital blocks for surgical procedures, the best evidence indicates that the use of lidocaine with epinephrine is equally safe and
efficacious for anesthesia.7
SURGICAL
Nonresponders to conservative therapy and patients with more severe lesions (substantial erythema, granulation tissue, and pus) need surgical
therapy.8,9 S O RⒸ Surgical interventions are more effective than nonsurgical interventions in preventing the recurrence of an ingrowing toenail.10
Surgical intervention involves partial or full nail plate avulsion. Usually it is only necessary to remove the part of the nail that is placing pressure on
the lateral nailfold (Figure 2003). S O RⒸ
Patients who develop recurrent ingrown toenails benefit from permanent nail ablation of the lateral nail matrix. This may be achieved with the
combination of partial nail plate avulsion plus phenol matrixectomy, which can cut recurrence rates by 90% (Figure 2004).810 S O RⒶ
Based on a Cochrane Systematic Review of surgical treatments for ingrowing toenails, nail avulsion with the use of phenol is more effective at
preventing symptomatic recurrence than nail avulsion without the use of phenol.10 They also found that postoperative treatments such as
antibiotics, manuka honey, povidoneiodine with paraffin, hydrogel with paraffin, or paraffin gauze reduced the risk of postoperative infection or
postoperative pain, or gave a shorter healing time.10 S O RⒶ
Chemical matrixectomy is performed mainly with phenol (fullstrength 88%), but 10% sodium hydroxide is another alternative. In a comparison
study of the use of chemical matrixectomy for the treatment of ingrown toenails, the overall success rates were 95% for both phenol and sodium
hydroxide.11 S O RⒶ
One study found that partial nail avulsion with phenolization gave better results than partial avulsion with matrix excision.12 Local antibiotics
applied to the surgical site did not reduce signs of infection or recurrence. The use of phenol did not produce more signs of infection than matrix
excision.12 S O RⒷ
Electrosurgical ablation can be performed with electrosurgery units on the fulguration setting or using a special matrixectomy electrode with a
highfrequency electrosurgical unit (Figure 2005). S O RⒸ
FIGURE 2003
Status post partial nail avulsion procedure for an ingrown toenail. (Reproduced with permission from Richard P. Usatine, MD.)
highfrequency electrosurgical unit (Figure 2005). S O RⒸ
FIGURE 2003
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Status post partial nail avulsion procedure for an ingrown toenail. (Reproduced with permission from Richard P. Usatine, MD.)
FIGURE 2004
Phenol matrixectomy to destroy a portion of the nail matrix to prevent a recurrent ingrown toenail. Note the use of a tourniquet to decrease bleeding
while applying the phenol with a twisting motion. (Reproduced with permission from Richard P. Usatine, MD.)
FIGURE 2005
Use of electrosurgery to ablate the lateral nail matrix. This results in a narrower nail and a decreased likelihood of onychocryptosis recurrence.
FIGURE 2005
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Use of electrosurgery to ablate the lateral nail matrix. This results in a narrower nail and a decreased likelihood of onychocryptosis recurrence.
FOLLOWUP
After surgical intervention, consider followup in 3 to 4 days to assess treatment and exclude cellulitis.
PATIENT EDUCATION
Patients should be educated about proper nail trimming so as to minimize trauma to the lateral nailfold. The lateral nail plate should be allowed
to grow well beyond the lateral nailfold before trimming horizontally.
Patients should also be educated about the importance of avoiding shoes that are too tight over the toes to help minimize recurrences.
PATIENT RESOURCES
Ingrown Toenails information at the familydoctor.org website—https://familydoctor.org/condition/ingrowntoenails/.
eMedicineHealth. Ingrown Toenails—http://www.emedicinehealth.com/ingrown_toenails/article_em.htm.
PROVIDER RESOURCES
Medscape eMedicine. Ingrown Nails—http://emedicine.medscape.com/article/909807.
Usatine R, Pfenninger J, Stulberg D, Small R. Dermatologic and Cosmetic Procedures in Office Practice. Philadelphia: Elsevier; 2012 (with DVD).
The "Nail Procedures" chapter provides details, photographs, and videos of how to perform ingrown toenail surgeries. Available as an
electronic app as well—http://usatinemedia.com.
http://itunes.apple.com/us/app/dermatologiccosmeticprocedures/id479310808?ls=1&mt=8.
REFERENCES
1. Siegle RJ, Swanson NA. Nail surgery: a review. J Dermatol Surg Oncol. 1982;8(8):659–666. [PubMed: 7119258]

2. Connolly B, Fitzgerald RJ. Pledgets in ingrowing toenails. Arch Dis Child. 1988;63:71. [PubMed: 3348654]
3. 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–
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REFERENCES
1. Siegle RJ, Swanson NA. Nail surgery: a review. J Dermatol Surg Oncol. 1982;8(8):659–666. [PubMed: 7119258]
2. Connolly B, Fitzgerald RJ. Pledgets in ingrowing toenails. Arch Dis Child. 1988;63:71. [PubMed: 3348654]
3. 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. [PubMed: 17062049]
4. Arai H. Formable acrylic treatment for ingrowing nail with gutter splint and sculptured nail. Int J Dermatol. 2004;43(10):759–765. [PubMed:

15485537]
5. Ishibashi M, Tabata N, Suetake T, et al. A simple method to treat an ingrowing toenail with a shapememory alloy device. J Dermatolog Treat.
2008;19(5):291–292. [PubMed: 19160535]
6. Reyzelman AM, Trombello KA, Vayser DJ, et al. Are antibiotics necessary in the treatment of locally infected ingrown toenails? Arch Fam Med.
2000;9:930. [PubMed: 11031403]
7. Altinyazar HC, Demirel CB, Koca R, Hosnuter M. Digital block with and without epinephrine during chemical matricectomy with phenol. Dermatol
Surg. 2010;36(10):1568–1571. [PubMed: 20698866]
8. Grieg JD, Anderson JH, Ireland AJ, Anderson JR. The surgical treatment of ingrowing toenails. J Bone Joint Surg Br. 1991;73:131. [PubMed:

1991748]
9. Vaccari S, Dika E, Balestri R, et al. Partial excision of matrix and phenolic ablation for the treatment of ingrowing toenail: a 36month followup of
197 treated patients. Dermatol Surg. 2010;36(8):1288–1293. [PubMed: 20573175]
10. Eekhof JAH, VanWijk B, Knuistingh Neven A, van der Wouden JC. Interventions for ingrowing toenails. Cochrane Database Syst Rev. 2012;
(4):CD001541.
11. Bostanci S, Kocyigit P, Gurgey E. Comparison of phenol and sodium hydroxide chemical matricectomies for the treatment of ingrowing toenails.
Dermatol Surg. 2007;33:680–685. [PubMed: 17550444]
12. Bos AM, van Tilburg MW, van Sorge AA, Klinkenbijl JH. Randomized clinical trial of surgical technique and local antibiotics for ingrowing toenail.
Br J Surg. 2007;94:292–296. [PubMed: 17318803]

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1. Siegle RJ, Swanson NA. Nail surgery: a review. J Dermatol Surg Oncol. 1982;8(8):659–666. [PubMed: 7119258]

1. Siegle RJ, Swanson NA. Nail surgery: a review. J Dermatol Surg Oncol. 1982;8(8):659–666. [PubMed: 7119258]

2. Connolly B, Fitzgerald RJ. Pledgets in ingrowing toenails. Arch Dis Child. 1988;63:71. [PubMed: 3348654]

4. Arai H. Formable acrylic treatment for ingrowing nail with gutter splint and sculptured nail. Int J Dermatol. 2004;43(10):759–765. [PubMed:

8. Grieg JD, Anderson JH, Ireland AJ, Anderson JR. The surgical treatment of ingrowing toenails. J Bone Joint Surg Br. 1991;73:131. [PubMed:

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