Review

Onychocryptosis – decrypting the controversies

Vishal Thakur 1, MD, Keshavamurthy Vinay 1,2, MD, DNB and Eckart Haneke 2, MD, PhD

–
1
Department of Dermatology, Venereology, Abstract
and Leprology, Postgraduate Institute of Onychocryptosis, or ingrown toenail, is a frequent, painful condition affecting young
Medical Education and Research,
individuals. Controversies still exist regarding its etiopathogenesis and treatment options,
Chandigarh, India, and 2Department of
including conservative and surgical techniques. The choice of treatment method depends
Dermatology, Inselspital, University of Bern,
on the stage of disease as conservative measures are mostly effective in early stages and

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Bern, Switzerland
surgical procedures are required in the later stages. Among surgical techniques, phenol
Correspondence MD MD, DNB MD, PhD
cauterization of lateral nail matrix has been the most effective, safe, and commonly
Review
Keshavamurthy Vinay, MD, DNB
performed method. Other more destructive surgical procedures are rarely done nowadays.
Department of Dermatology, Venereology,
Vishal Thakur ,
and Leprology
, Keshavamurthy
In this review, weVinay , the etiopathogenesis,
briefly discuss and Eckart Haneke
clinical features, ,
and different
Postgraduate Institute of Medical Education treatment options of ingrown toenail.
and Research
Onychocryptosis
Chandigarh-160012 decrypting the controversies
India
E-mail: vinay.keshavmurthy@gmail.com

Conflict of interest: None.

Funding source: None.

doi: 10.1111/ijd.14769

equally; however, a few studies have demonstrated a predomi-

Introduction
Onychocryptosis (onyx - nail and kryptos - hidden), also known
as “ingrown (toe) nail” or “unguis incarnatus”,1 is a common
condition of the nail characterized by pain, discharge, and swel-
ling of the nail fold. Most physicians call this condition ingrown
toenail (unguis incarnatus) since the growth of nail plate into the
nail fold is believed to be the main event, whereas others insist
it to be named onychocryptosis because the normal nail plate is
embedded into the hypertrophic lateral nail fold tissue.2 It
describes the puncture of the periungual skin by the nail plate
leading to an inflammatory reaction causing an excessive for-
mation of granulation tissue at the nail fold.
nant lateral toe involvement over the medial side. 6
Predisposing factors
Onychocryptosis predominantly occurs in young individuals; how-
ever, congenital onychocryptosis and ingrown toenails in older
individual have been described. Various predisposing factors are
implicated in the etiology, which include poorly fitting shoes, tight
socks, hyperhidrosis, and trauma.2 Predisposing factors in young
and old individuals are summarized in Table 1. Hyperhidrosis and
increased sports activities in younger individuals lead to softer
Table 1 Predisposing factors for onychocryptosis

Epidemiology Young individuals Old individuals

Onychocryptosis is one of the most common nail problems with Poorly fitting shoes Thick nails
3 and tight socks Poor nail care
a prevalence known to be as high as 2.5–5%. In a nationwide
Hyperhidrosis and Wider and thicker nail fold
population-based study, the overall incidence of ingrown toe-
increased sports activities Increased curvature of
nails in South Korea was found to be 307.5/100,000 person- Trauma the nail plate (pincer nails)
years with a bimodal distribution of age, that is, 15 and Improper cutting of the Diabetes
50 years.4 The highest incidence is seen in the second and toenails, that is, too short Obesity
or rounding the nail Thyroid, cardiac, and renal diseases
third decade with a male : female ratio of 2 : 1. 5 Onychocrypto-
Obesity
656 sis affects both the medial and lateral nail folds of the hallux

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Thakur, Vinay, and Haneke
nail folds, and tight footwear causes extrinsic compression caus-
ing nail spicules to pierce into the nail fold. In older individuals,
thick nails and poor nail care cause more pressure on the nail fold
leading to ingrown toenails. Nail anatomy such as wider and
thicker nail fold, medial rotation of the hallux, increased curvature
of the nail plate (pincer nails), and decreased nail thickness with
sharp nail margins are possible risk factors.7 Improper cutting of
the toenails, that is, too short or rounding the nail, also predis-
poses to onychocryptosis. This leads to impingement on the lat-
eral edges of the nail causing inflammation and pressure
necrosis.7 Congenital malalignment of the great toenail may also
lead to onychocryptosis, although this is actually very rarely the
cause of ingrown nails. However, a genetic predisposition has
been noted with some familial cases.8 Several comorbidities, like
diabetes, obesity, cardiac, and renal diseases, have been associ-
ated indirectly with increased rates of ingrown toenails, particu-
larly in older patients owing to lower extremity swelling in these
diseases causing excessive pressure on the nail apparatus.9
Finally, certain drugs, such as indinavir and ritonavir,10 doc-
etaxel,11 cyclosporine,12 isotretinoin,13 and oral antifungals,14
have also been implicated in ingrown toenails. Oral antifungals
may cause ingrown nails as they may normalize the width of the
nail distally, thus causing impingement of the corners into the dis-
tal lateral nail folds that had narrowed because of transverse
shrinkage of the distal nail bed.
Pathogenesis
Various theories have been proposed in the pathogenesis of
onychocryptosis. However, controversy still exists whether the
nail plate is the cause or hypertrophic nail fold tissue is the real
culprit.2 Various mechanisms leading to the development of
onychocryptosis may include15: epidermal break in the lateral
nail fold as a result of constant pressure from the nail plate
against the soft tissue, pinching of the subungual soft tissue
because of repetitive trauma and widening of the base of the
distal phalanx causing narrowing and elevation of the distal part
of the nail plate,16 and periungual tissue swelling leading to an
inflammatory reaction, fibrosis, and embedding of the lateral
part of nail plate.
Types of onychocryptosis
Six major types of ingrown toenail have been described17
(Fig. 1):
1 Subcutaneous ingrown toenail
2 Hypertrophy of the lateral nail fold
3 Inward distortion of the nail
4 Distal nail embedding
5 Ingrown toenail of infancy
6 Retronychia
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Onychocryptosis – decrypting the controversies Review 657
Clinical presentation
The most common symptom is toe pain, which may cause diffi-
culty in walking, wearing shoes, and inability to ambulate. In ini-
tial stages, there is erythema and mild swelling, and in later
stages, hypertrophic nail folds with granulation tissue and
serosanguinous or purulent discharge (secondary to chronic irri-
tation by ingrown nail plate) are seen. Sometimes in advanced
stages, excessive granulation tissue forms over the nail fold.
Although very often wrongly claimed as pyogenic granuloma, it
is simply excessive granulation tissue.
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Staging
In 2002, Mozena described four stages of ingrown toenail on the
basis of depth of ungula fold inflammation, that is, stage I, IIa, IIb,
and III (Fig. 2).18 This classification is not really different from the
“classical” one of Heifetz that dates back to 1935, and it only
adds/separates stage II as a and b. In 2007, Martinez-Nova fur-
ther defined stage IV of ingrown toenail (Table 2).19 In 2008, Kline
proposed a new classification system which addressed the risk of
complications like osteomyelitis in the classification and treatment
algorithm.20
Complications
Purulent discharge of the nail fold is common, and it sub-
sides by itself after phenolization, as the real cause is the
irritation caused by the nail plate that has pierced into the
soft tissue. Scarring, cellulitis, and osteomyelitis21 are some
very rare complications of onychocryptosis but should always
be considered and not overlooked. Onychocryptosis may lead
to amputation and some fatal infections in immunosuppressed
patients.
Diagnosis
The diagnosis of onychocryptosis can most often be easily
established by clinical examination. However, it must be differ-
entiated from many bone and cartilaginous tumors as they
may simulate it and cause nail plate deformation and impinge-
ment of soft tissue on the nail plate, leading to onychocrypto-
sis. Standard radiographs of the affected toe should be done
to visualize these tumors. However, radiography is not always
helpful, especially in cases of cartilaginous tumors, and other
imaging techniques like ultrasonography or MRI may be
needed. The common osseous and cartilaginous tumors to
consider include exostosis, osteochondroma, enchondroma,
and chondrogenic sarcomas.1 Other tumors that need to be
differentiated include fibrokeratomas, basal cell carcinoma,
squamous cell carcinoma, melanoma, glomus tumor, and Mer-
kel cell tumor.
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658 Review Onychocryptosis – decrypting the controversies
(a) (b)
(c) (d)
Management
The management of onychocryptosis depends on the stage of
the disease as a conservative approach can be adopted in early
stages, while definitive surgical procedures may be required at
later stages. There are various surgical procedures for the man-
agement of onychocryptosis. However, considering the lack of
evidence on the “ideal” surgical procedures and the controversies
surrounding the etiopathogenesis of onychocryptosis, it being a
hypertrophic nail fold disease or an abnormal nail plate disorder,
the choice of procedure more often depends on the expertise and
specialty of the treating physician than the stage of the disease.
Conservative approaches
Early stage onychocryptosis (Stage I and IIa) usually respond
to conservative treatment alone, obviating the need for a surgi-
cal procedure. In patients with more severe disease, surgical
treatments achieve satisfactory and rapid cure. But in patients
who fear surgery, and those with associated comorbidities like
International Journal of Dermatology 2020, 59, 656–669
Thakur, Vinay, and Haneke
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Figure 1 Clinical types of ingrown toenail,
(a) hypertrophy of the lateral nail fold; (b)
inward distortion of the nail; (c) distal nail
embedding; (d) ingrown toe nail of infancy
vascular compromise or diabetes, nonsurgical management
may provide symptomatic relief.
The aim of conservative management is to protect the nail
fold from the distal nail plate and to obviate the need of surgery.
Various factors, such as proper footwear (wide toe box or open
toe shoes), straight cutting of the nails instead of round cutting,
and management of coexisting hyperhidrosis and onychomyco-
sis, should be taken into consideration. Soaking of the foot or
affected toe in warm water for 15–20 minutes followed by appli-
cation of topical antiseptics may help to decrease inflammation
and secondary infection if any. Various conservative techniques
exist which include:
1 Nail Fold Taping – Taping was first described by Nishioka
et al. 22 and is useful in early stages of onychocryptosis. The
basis of this technique is to pull out the lateral nail fold away
from the distal or lateral nail plate to decrease pressure. An
elastic adhesive tape of approximately 15–20 mm in width is
pressed over the lateral nail fold as close as possible to the
nail plate and once secured, it is pulled away from the nail in
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Thakur, Vinay, and Haneke Onychocryptosis – decrypting the controversies Review 659

Figure 2 Clinical stages of ingrown toenail;

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(a) stage 1 – toenail showing mild erythema,
and edema; (b) stage 3 – toenail with
granulation tissue and chronic hypertrophy (a) (b)
of nail fold

an oblique and proximal direction without impairing the joint
movement (Fig. 3).2 A second tape is placed over the first
one to exert more pressure. The limitation of this method is
the complexity of the procedure. To achieve good results, it
has to be performed correctly in a consistent manner.
Another limitation of this method is decreased adhesiveness
with time because of sweating and wet granulation tissue
2 Acrylic artificial nails – The artificial nail adheres by itself, as
it is an acrylate polymer. Acrylic nails are indicated in distal
ingrown nails. The artificial nail is pasted to the distal end of
the nail with the help of cyanoacrylate glue, and it helps the
distal nail in regaining a physiological shape. After this, the
artificial nail can be removed simply by trimming the free
edge till the natural nail plate.23
3 Nail packing – Packing is another simple technique in which
a cotton wisp is inserted underneath the distal nail plate cor-
ner (Fig. 4). The procedure needs to be repeated daily with
Table 2 Martinez-Nova classification system for onycho-
cryptosis.17
more cotton to be filled. Initially, the procedure is painful, but
patients quickly report self-relief subsequently. Antiseptics or
disinfectants may be dropped on the cotton wisp to prevent
secondary infection. The cotton may be fixed with cyanoacry-
late glue for 1 week once the nail is no longer embedding into
the nail fold. This is an effective method in stages 1 and 2
ingrown toenail, avoiding the need for surgery.24
4 Dental floss – This technique is similar to the nail packing
method with cotton. In this, dental floss is inserted obliquely
beneath the lateral nail plate (Fig. 5).25 This is easy to per-
form with a significant chance of long-term remission from
onychocryptosis.
5 Gutter technique/Sleeve technique or nail tube splinting –
This technique consists of using a sterile plastic tube (a vinyl
intravenous drip infusion tube) insertion over the lateral bor-
der of the nail plate to separate it from the lateral nail fold
(Fig. 6).26 After local anesthesia, the distal edge of the nail
plate is elevated with a mosquito forceps and separated from
the lateral nail fold. The free lateral edge is then splinted with
a lengthwise cut plastic tube, which is fixed with adhesive

Stage Clinical features

I Erythema, slight edema, and pain

Nail fold does not exceed the limits of the nail plate
IIa Increased pain, edema, erythema, hyperesthesia,
serous drainage, and/or infection
Nail fold exceeds the nail plate <3 mm
IIb Increased pain, edema, erythema, hyperesthesia,
serous drainage, and/or infection
Nail fold exceeds the nail plate >3 mm
III Granulation tissue and chronic hypertrophy of the nail fold
Granulation or hypertrophic tissue widely covers the
lateral nail plate
IV Serious chronic deformity of the toenail, both lateral
nail folds and distal fold
Figure 3 Schematic representation of nail taping, arrows indicate
Hypertrophic tissue completely covers lateral, medial, and
direction of the force applied on the tape to keep nail fold separated
distal nail plate
from nail plate

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660 Review Onychocryptosis – decrypting the controversies
Figure 4 Schematic representation of nail packing with a wisp of
cotton
tape or cyanoacrylate. This tube is left for a few weeks or
months until a normal nail will have grown over the nail fold.
The plastic tube requires regular trimming to keep it at the
level of the distal nail plate and would eventually fall off with
the growth of the nail plate. In a study by Schulte et al., this
technique was found to be very effective in 62 patients with
no recurrences.26 As per the authors’ experience, this tech-
nique has a good success rate in patients of early stage ony-
chocryptosis.
6 Nail brace technique – This technique, also known as “ortho-
nyxia” (ortho- straight, onyx- nail), is inspired from dental
braces (orthodontia). It aims to straighten a transversely over-
curved nail and allows the nail to grow flat over time.2 Nail
braces are of two types – adhesive and hooked. Adhesive
braces are made up of a thin strip of composite material,
which attempts to return to its natural flat shape after fixing to
the curved nails. This results in lifting of the lateral ends of
nail plate. Hooked braces result in upward tension at the lat-
eral nail plate by metallic hooks placed under the lateral nail
plate margins.27 However, placement of the hooks under the
nail plate is very painful. The nail brace technique, particularly
(a) (b) (c)
International Journal of Dermatology 2020, 59, 656–669
Thakur, Vinay, and Haneke
adhesive brace, is a safe and effective treatment option for
onychocryptosis, but recurrence is the limitation of this proce-
dure. In certain countries, the procedure of orthonyxia is not
covered by insurance, and high costs and limited availability
of the expertise are its drawbacks.
7 Other conservative methods – Additionally, few conservative
methods that have been described in literature include nail
wiring, shape memory alloy nail braces, and angle correction
technique.
Surgical management
Numerous surgical techniques have been reported in the litera-
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ture for onychocryptosis but none has emerged as the tech-
nique of choice. Many studies have reported superiority of one
technique over another, which may have been biased consider-
ing the surgical skills of the surgeon as better outcomes are
usually achieved with familiar procedures. Owing to the contro-
versy in the etiopathogenesis of onychocryptosis, procedures
primarily based on nail plate or nail folds have been used over
the years with variable success and recurrence rates. The
choice of surgical procedure mainly depends on the stage of
ingrown toenail, type of ingrown toenail, and operator skills.
Sometimes, a cocktail of different surgical procedures can be
performed on a single ingrown toenail to obtain optimal results.
A Cochrane review of nine randomized controlled trials con-
cluded that phenol cauterization with nail avulsion decreases
the recurrence rate at the cost of increased infection.28 How-
ever, post-phenol care is very important as this is often
neglected and rarely described in the literature. The ideal surgi-
cal technique would have a good functional and aesthetic out-
come, minimum downtime, and a low recurrence rate.
Preoperative evaluation
A thorough history, especially regarding peripheral vascular dis-
ease, diabetes, smoking, and drugs, and full clinical evaluation
should be done in all patients. The patients should be informed
about the surgical technique, downtime, potential complications,
and outcome.
Figure 5 Dental floss insertion for ingrown
fingernail; (a) ingrown finger nail, (b) and (c)
images showing dental floss inserted
obliquely beneath the lateral nail plate
ª 2020 The International Society of Dermatology
Thakur, Vinay, and Haneke
Figure 6 Nail tube splinting (gutter
splinting); (a) Ingrown toenail (b) a vinyl
intravenous drip infusion tube, (c) lateral
edge of nail plate with nail tube inserted
along it (a)
Instruments
Depending on the surgical technique, an ingrown toenail sur-
gery tray for matricectomy and removal of soft tissue should
have the following (Fig. 7) 29:
• English nail splitter
• Needle holder with serrated jaws, for holding larger needles
(4/0 and over)
• Sturdy straight hemostat, at least two
• Freer septum elevator
• Fine curved scissors, Iris or Gradle type
• Fine Adson plane and toothed 2 9 1 forceps
• Bard-Parker blade holder, with blade number 15
• Curette, excavator type (Besnier lupus or Volkmann curettes)
• Tourniquet
• Nonabsorbable 3/0 and 4/0 and absorbable 4/0 and 5/0
sutures
Anesthesia
A proper knowledge of the nerve supply and anatomy of the toe
is the prerequisite for ingrown toenail surgery to avoid vascular
complications and serious complications like toe necrosis. Lig-
nocaine solution 1% or 2% is used; 2% is preferred as it
requires a smaller volume and is more efficient. Ropivacaine
0.5 or 1% is a very valuable alternative as it has an onset almost
Figure 7 Surgical instrument tray for matrixectomy and soft tissue
removal
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Onychocryptosis – decrypting the controversies Review 661
(b) (c)
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as fast as lignocaine and a duration of anesthesia of 10–
12 hours or longer. Epinephrine with lignocaine is safe in digital
anesthesia30 and prolongs the duration of anesthesia with
reduced risk of immediate bleeding.31 However, delayed bleed-
ing can occur with the use of epinephrine containing lignocaine.
Various digital blocks include proximal digital block, distal dig-
ital block, and so-called distal wing block. The procedure of dis-
tal digital block and distal wing block is almost the same. In
proximal digital block, the needle is inserted in the midline of
the lateral and medial aspect of the proximal phalanx, with an
angle of 45° from the proximal bony phalanx, 1 cm distal to the
web space (Fig. 8a). The needle is pushed till it touches the
bone and is slightly withdrawn. Approximately 1.5–2 ml of anes-
thetic agent is injected into each side to produce adequate
anesthesia within 10–15 minutes.
In distal digital block, the injection is given at a point about
1 cm proximolateral to the junction of the proximal nail fold and
the lateral nail fold (Fig. 8b). By directing the needle at a 45°
angle directed distal down to the bone, about 0.5 ml of anes-
thetic is slowly injected until blanching of the lunula indicates
adequacy of anesthesia. This will result in anesthesia of the
dorsal nerve. Further, the needle is slightly withdrawn and
pushed downward just lateral to the bony phalanx until it
reaches the ventral pulp followed by injecting another 0.5 ml of
anesthetic into the space.
In the distal wing block, a periungual block is given where the
initial step is similar to the distal digital block followed by
repeated injection of the anesthetic agent into the lateral nail
fold progressing up to the tip of the digit. The needle may be
bent at 120° to facilitate the injection within the whole length
of the lateral fold, limiting the number of punctures. The
procedure is repeated on the opposite side to achieve complete
anesthesia.
Avulsion
Nail avulsion is the surgical removal of nail plate either partially
or totally. Nail avulsion alone is not recommended for lateral
ingrown toenail as it has been associated with significant post-
operative morbidity and high recurrence rates.2 However, it still
remains an effective treatment option for retronychia.
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(a)

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(b) Figure 8 Techniques of proximal digital
block (a) and distal digital block (b)

longer downtime and risk of complications, wedge resection is

Surgical resection of the matrix horns
rarely used to treat onychocryptosis.
“Classical” wedge resection
Wedge excision is a relatively simple and classic technique and
Physical destruction of matrix horns
involves resection of the lateral nail plate, nail bed, and matrix. It is
suitable for stage IIb and III. Success rates of this procedure Electrosurgery
depend on the skills of the surgeons. Various modifications of this Electrocautery is an effective and safe alternative option for
procedure have been described in the literature. Winograd’s destruction of matrix horns. This procedure uses electric current
method employs partial matricectomy, which involves a “D” shaped
excision removing lateral nail plate, nail bed, lateral nail matrix, and
lateral nail fold (Fig. 9a). Emmert’s or Kocher’s wedge excision,
another technique commonly used by surgeons, involves removal
of the lateral matrix and overlying proximal fold, the lateral nail fold
to the hyponychium. 2 As it is commonly performed in the wrong
manner, the recurrence rate is between 20 and 70%. In Frost’s
modifications, an “L” shaped incision is made to expose and excise
the matrix horn selectively (Fig. 9b). Suppan’s modification
involves curetting of the nail matrix horn along with avulsion of the
lateral nail plate. Curetting the matrix horn has the disadvantage
that the round curette has to remove the tip of the matrix horn,
which is usually sharp angled. Zadik’s and Kaplan’s modifications
involve complete matricectomy and are completely obsolete.
Wedge excision is associated with significant postoperative pain
and morbidity as well as a high risk of infection. A long time for
healing is required. A recent study compared Winograd’s method
with the sleeve technique and found similar recurrence rates and Figure 9 Various procedures for surgical resection of matrix horns;
shorter duration for healing.32 In the authors’ practice, in view of its (a) Winograd’s procedure; (b) Frost’s procedure

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Thakur, Vinay, and Haneke
to cause tissue necrosis. Ozan et al. compared partial matricec-
tomy with electrocautery and curettage and found both methods
to be effective with high success rates.33 However, postopera-
tive inflammation and pain were more intense with electro-
cautery. In another study, comparison of phenol cauterization
with electrocautery showed similar recurrence rates but shorter
healing time with phenol.34 It is important to note that no matrix
horn must remain, but at the same time, as a lot of heat is
delivered to the tissue, thermal periostitis with long-term pain
may occur as a complication.2
Radiosurgery
This technique causes selective tissue necrosis with a narrow
margin of thermal tissue damage as the electrode itself is cold
and heat is generated in the tissue. The electrode of the radiofre-
quency device is inserted beneath the proximal nail fold into the
lateral matrix horn after removal of a lateral strip of nail plate.
Power and time settings depend on the device and personal
experience. As it is more selective than electrocautery, healing is
faster with less scarring. However, this should not be performed
in patients with metallic implants like electrocautery. Results
reported are comparable to phenol cauterization,35 but larger
(a)
Figure 10 Partial lateral nail plate avulsion
with chemical matrixectomy; (a) ingrown
toenail grade 3, (b) and (c) lateral nail plate
avulsion, (d) chemical cauterization of lateral
nail fold with 88% phenol, (e) cauterized
(d)
proximolateral nail matrix
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Onychocryptosis – decrypting the controversies Review 663
studies on this method are required. Complications are similar to
electrocautery.
Laser
Laser treatment for destruction of matrix horns has been used
widely, CO2 laser being the most frequent. 36–38 Erbium-YAG
laser has also been used for a modified wedge excision.39 Laser
matrix ablation is a highly operator-dependent method requiring
excellent knowledge of nail matrix anatomy and laser devices.
The matrix horn is vaporized with the CO2 laser after removal of
the lateral nail plate. The lateral matrix can be stained with methy-
lene blue to visualize the matrix and achieve adequate ablation.40
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Advantages of laser matrix ablation are less pain, short operative
and healing time with minimum disability, and less bleeding.2
Recurrence rates with laser ablation have been found higher than
chemical matricectomy.41,42 However, additional lateral nail fold
ablation resulted in decrease in recurrence rates from 37.5% to
6.2% with matrix ablation alone.43 Radiofrequency and CO2 laser
are virtually equally effective and tissue damaging, but the cost of
radiofrequency device is much less as compared to CO2 laser.
High costs and a lower success rate compared to phenol cauteri-
zation limit the use of this technique in the authors’ practice.
(b) (c)
(e)
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Table 3 Studies on chemical matrixectomy with recurrence rates

Duration of
Sample follow-up Recurrence
Method Year Author Size (months) rate (%) Comments

Phenol 1995 Kimata et al. 64 537 6 1.1 Easy to perform

Can be done in the presence of secondary infection
Postoperative pain is minimal
2001 Bostanci et al. 65 350 25 0.57 Simple method with low morbidity and high success rate
2004 Andreassi et al. 66 948 18 4.3 Simple and consistently effective method when conservative
treatment fails and in cases of recurrence, with minimal
postoperative discomfort
2009 Tatlican et al. 67 148 24 Compared phenol applications of different durations

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No significant difference between the groups with respect to the
recurrence rates, with 1 minute phenol application having better
safety profile
2012 Karaca et al. 68 348 24 0.3 Phenolic ablation is highly effective and the treatment of choice
2013 Zaraa et al. 69 171 21 2.7 Recommended as treatment of choice of ingrown toenails
NaOH 10% 2004 Ozdemir et al. 70 156 16 0 NaOH applied for 2 minutes or 1 minute in combination with
curettage is a good alternative for the treatment of ingrown
toenails with 100% success rate, safety, and minimal morbidity
Both procedures seem to be equally effective and curettage of
the matrix area followed by 1 minute contact of NaOH can be
preferred to prevent side effects of chemical contact
2005 Kocyigit et al. 51 226 14 4–21 Compared different durations of application of NaOH
1- and 2-minute application is more effective than 30-second
application
2010 Tatlican et al. 71 81 24 2.4 Faster healing, less complications, and recurrences suggest that
it is safer and more effective than phenol
TCA 2009 Kim et al. 53 40 23 5 High success rates with good cosmetic results and minimal side
effects
2015 Terzi et al. 72 56 12 1.8 Safe, simple, and effective method with less postoperative
morbidity and high rates of success. Can be used as an
alternative treatment method
BCA 2017 Terzi et al.54 58 12 1.8 First study to use BCA
Safe, simple, and effective method

BCA, bichloroacetic acid; NaOH, sodium hydroxide; TCA, trichloroacetic acid.

Cryotherapy Two recent Cochrane reviews of surgical modalities for ingrown

Sonnex and Dawber first used cryotherapy for ingrown toenails
with granulation tissue and reported success rates of 63.8%.44
Later, Masters also reported similar success rates but with high
recurrence.45 However, in these studies, only cryotherapy was
performed without matricectomy, which may have led to higher
recurrences. Recently, a comparison between matricectomy
with electrocautery and cryotherapy reported both methods to
be equally effective with high success and low recurrence
rates.46 The duration of application of liquid nitrogen to the nail
matrix has not yet been standardized. However, in a recent
study, liquid nitrogen was sprayed from a distance of 5–10 mm
with spot freezing technique for 45 seconds and reported only
two recurrences out of 76 ingrown toenails after 12 months.47
Chemical destruction of matrix horns
Nail matrix cauterization with phenol is the most effective and
commonly employed technique in the authors’ practice (Fig. 10).
toenail showed phenol cauterization to be associated with lowest
morbidity and recurrence at 6 months or more. 28,48 Phenol has
a few added advantages such as its antiseptic, anesthetic, and
protein coagulant properties, which help in reducing bleeding,
postoperative infection, and pain. Phenol ablation is usually done
at the lateral matrix horn for 2–3 minutes, after which some
authors prefer to flush the treated area with alcohol to dilute the
remaining phenol.49 It is important to ensure the exsanguination
of the digit using a tourniquet and the matrix area and nail sulcus
should be dry before applying phenol as body fluid neutralizes
the chemical. Care should be taken as not to spill phenol over
lateral nail folds, which would increase postoperative discharge
and down time. Histopathological analysis of cadaver matrix
after phenol ablation has revealed that duration of phenol appli-
cation less than 2 minutes is unable to cauterize the matrix
basal cell layer.50 However, prolonged application may result in
excessive oozing. Use of 20% ferric chloride application after
phenol cautery has shown to reduce oozing.51

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Thakur, Vinay, and Haneke Onychocryptosis – decrypting the controversies Review 665

Sodium hydroxide (NaOH) is another chemical agent, which

is alkaline and causes liquefaction necrosis that heals faster in
contrast to coagulative necrosis caused by phenol.29 Thus,
chemical matricectomy using NaOH is expected to shorten the
duration of healing. Different durations of NaOH application
have been studied showing 1 minute application to be most
effective with minimal side effects.52 Complications associated
with NaOH matricectomy include nail dystrophy, allodynia, and
hyperalgesia.53 Chemical matricectomy with trichloroacetic
acid54 (TCA) 100% and bichloroacetic acid55 (BCA) 90% has
been described with equal efficacy to phenol matricectomy.
Major studies of chemical matricectomy and their comparisons
Resection of soft tissue
Ingrown toenails lead to lateral nail fold hypertrophy as a conse-
quence of piercing of the nail margin into the skin owing to pro-
gressive pressure. The nail fold subsequently develops
granulation tissue and fibrosis, which turns into sclerosis with
no tendency to return to its normal shape and size. Procedures
primarily based on nail plate narrowing do not usually help in
this situation, and surgical techniques removing the excessive
nail fold tissue should be done. Various methods of soft tissue
excision have been described with few modifications.

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with other surgical methods in the treatment of ingrown toenail Howard-Dubois procedure
are illustrated in Tables 3 and 4, respectively. Details of differ- Howard described this procedure in the late 19th century, and it
ent chemical agents for matricectomy are described in Table 5. was reintroduced by Dubois after 80 years in France.2,56 This

Table 4 Comparative studies of chemical matrixectomy with other methods

Duration of
Sample follow-up Recurrence
Method Year Author size (months) rate (%) Comments

Phenol vs. wedge 1990 van der Ham et al .73 249 14 9.6 vs. 16 Phenol gives better short- and long-term
excision results than wedge excision
2001 Herold et al.74 110 11 5.5 vs. 0 Phenol is an efficient therapy and may be
preferred over wedge excision
Phenol vs. nail tube 2014 AlGhamdi et al. 75 30 vs. 23 6 3 vs. 4 Sleeve method is more comfortable
splinting (sleeve Excellent cosmetic results with sleeve method
method) because of greater matrix conservation and
regrowth of a normal nail
Postoperative shoe-wearing discomfort and
pain are less with sleeve method
Phenol vs. 2014 Misiak et al.33 30 each 3 17 vs. 27 No significant difference between both
electrocautery methods in terms of relapse
Healing time shorter with phenol, that is, 4.5
times faster than electrocautery
Phenol 88% vs. NaOH 2007 Bostanci et al.76 72 vs. 82 19 4.2 vs. 4.9 NaOH seems superior providing faster
10% recovery with respect to cessation of
drainage and healing of periungual tissue
2015 Grover et al.77 26 vs. 23 6 0 vs. 4 NaOH is equally effective as phenol, with
faster healing and slightly less adverse
effects
Phenol vs. TCA 2018 Andre et al. 78 46 vs. 50 4 NM Both methods highly effective (100%)
Postoperative oozing longer with TCA
The postoperative pain was similar and low for
both methods but significantly lower for
phenol
Phenol induces less inflammation than TCA
Phenol vs. surgical 2002 Gerritsma-Bleeker et al.79 29 vs. 34 12 24 vs. 20 Partial matrix excision is preferable over
matrixectomy (SM) phenol because toxic agent phenol should be
avoided
There is a need for further improvement in
treatment of ingrown toenails
2017 Romero-Perez et al.80 520 Retrospective 18 vs. 8 SM was associated with less recurrence rates,
analysis more pain, higher risk of infection, and lower
cosmetic satisfaction

NaOH, sodium hydroxide; TCA, trichloroacetic acid.

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666 Review Onychocryptosis – decrypting the controversies
Table 5 Different chemical agents used in matrixectomy for ingrown toenail
Agent Concentration Time Advantages
Phenol 88% 2–3 minutes Low recurrence, less postoperative pain
NaOH 10% 30 seconds to 3 minutes Fast healing
TCA 100% 1 minute Short healing time, can be stored for longer duration
NaOH, sodium hydroxide; TCA, trichloroacetic acid.
method is most suitable for distal embedding of the nail. Distal
hypertrophic soft tissue is excised in a fish-mouth manner and
sutured, which leads to the pulling down of the tissue and decom-
pression of the nail plate. Overtightening of suture after removal of
excess soft tissue should be avoided to prevent necrosis. A slight
modification of this procedure, in which excision of a triangular
piece from lateral nail fold is performed, has been described.57 The
distal bulge/false distal nail fold is not a hypertrophy of tissue as it
is because of gradual dorsal dislocation of the toe pulp. In long-
standing cases, there is very often a distal dorsal traction osteo-
phyte, which can be seen on a lateral-view radiograph and should
be removed in order to allow the distal bulge to be pulled down.
Vandenbos procedure
In 1959, Vandenbos and Bowers described this procedure, in
which a big chunk of soft tissue is removed without touching the
nail plate, nail matrix, and bed. The wound is left to heal by sec-
ondary intention.58 In this method, a “V” shaped excision is per-
formed starting in the proximal nail and taking out the entire
lateral fold to only leave a bridge at the hyponychium over the
distal central pulp. Peres Rosa described the “super U” tech-
nique, in which a “U” shaped excision is done with removal of
the lateral folds and also the distal pulp.59 The main limitation of
these methods is the long healing time, which may take even
months. In a study, excellent cosmetic outcomes with 100%
cure rate has been reported with this procedure.60
Noel’s procedure
Noel’s procedure is a variant of Howard-Dubois procedure, in
which the lateral nail folds are incised in a vertical manner and
Figure 11 Schematic representation of Noel’s procedure
International Journal of Dermatology 2020, 59, 656–669
Thakur, Vinay, and Haneke
Disadvantages
Longer duration of oozing, rare systemic toxicity
Postoperative pain, alkali burns
Pain, postoperative oozing
excessive soft tissue is removed (Fig. 11).61 This technique is
best suited for one or both hypertrophic lateral nail folds. This
method has certain advantages such as good cosmetic out-
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come, early healing, and no risk for nail dystrophy. It is limited
to noninfected cases.
Tweedie and Ranger flap
This procedure consists of an incision in the lateral nail fold fol-
lowed by curetting of soft tissue in a way to make a transposition
flap, which is sutured later (Fig. 12).62 High success rates have
been reported with pain being the most common complication.
In the authors’ experience, treatment of nail folds alone (with-
out treating the nail plate/matrix) is associated with high recur-
rence rate. However, these procedures are generally combined
with chemical matricectomy in patients with excessive granula-
tion tissue or sclerosis of the lateral nail folds.
Surgical procedures for pincer nails
Widening of overcurved nails is the main aim to alleviate pain
and improve the aesthetics of the nail. This can be achieved by
either flattening or removing the dorsal distal tuft of the bone
and spreading the nail bed or by elevating the lateral part of nail
bed. Various procedures have been described which involve
complete avulsion of nail plate with removal of bony tuft (Suzu-
ki’s method, Kosaka’s variant, and Fanti’s variant) and removal
of bony tuft with cauterization of matrix horns and nail bed
plasty (Haneke’s method). These procedures have high success
rates achieving more than 80% with Haneke’s method.63
Another method for mild overcurvature is Zook’s procedure,
Figure 12 Schematic representation of Tweedie and Ranger flap;
(a) incision in the lateral nail fold and removal of granulation tissue;
(b) transposition flap sutured
ª 2020 The International Society of Dermatology
Thakur, Vinay, and Haneke Onychocryptosis – decrypting the controversies Review 667

which involves elevation of nail plate with placement of dermal c Duration of phenol application less than 2 minutes is
grafts in the lateral nail bed.64 unable to cauterize the matrix basal cell layer.
d Wedge excision is a relatively simple and classic technique
Complications and most suitable for stage IIa.
5 Which of the following is a conservative method in treatment
Surgical procedures for onychocryptosis can be associated with of ingrown toenail?
complications and timely recognition of which is of utmost a Tweedie and Ranger flap
importance. Complications include bleeding, infection, pain, b Gutter technique
necrosis, recurrence, and nail dystrophy. Other rare complica- c Noel’s procedure
tions may be implantation cyst, hypertrophic scar or keloid, and d Zook’s procedure
reflex sympathetic dystrophy. 6 Application time for phenol cautery is:
a 2–3 minutes
Conclusion

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b 30 seconds to 3 minutes
c 1 minute
The management of ingrown toenails continues to be a thera-
d 1–2 minutes
peutic challenge, as controversies regarding its pathogenesis
7 Which of the following is not a method of surgical resection of
still exist. Various surgical methods described above have cer-
the matrix horns?
tain advantages and limitations. Thus, the choice of procedure
a Winograd’s method
in a particular patient depends on the stage and type of nail
b Suppan’s method
abnormality as well as surgeon’s skills and expertise. All proce-
c Kosaka’s method
dures have shown considerably high success rates when per-
d Frost’s method
formed by experts. Chemical matricectomy with phenol has
8 “Super U” technique of removal of soft tissue was developed by:
been reported as the best method for treatment of onychocryp-
a Vandenbos
tosis in the literature, but the ideal method for treatment of
b Howard-Dubois
ingrown toenail is still to be elucidated.
c Peres Rosa
d Sonnex and Dawber
Questions (answers provided after
9 Which of these is used to reduce excessive oozing after phe-
references)
nol cauterization?
1 Which of the following drugs is not implicated to cause a 10% aluminium hydroxide
ingrown toenail? b 20% ferric chloride
a Docetaxel c 20% calcium chloride
b Doxycycline d 10% sodium hydroxide
c Cyclosporine 10 Which of the following is not true?
d Oral antifungals a Epinephrine with lignocaine prolongs the duration of anes-
2 Which of the following is not a risk factor for ingrown toenail? thesia.
a Poorly fitting shoes b Epinephrine with lignocaine is not safe in digital anesthesia
b Improper cutting of nails as there are high chances of digital necrosis.
c Hypohidrosis c Delayed bleeding can occur with the use of epinephrine
d Trauma containing lignocaine.
3 Which of these classifications of ingrown toenail have d Epinephrine with lignocaine reduces the risk of immediate
addressed the risk of complications and treatment algorithm? bleeding.
a Mozena
b Kline References
c Martinez-Nova
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520 procedures. Int J Dermatol 2017; 56: 221–224.
Answers to questions
1 (b)
2 (c)
3 (b)
4 (d)
5 (b)
6 (a)
7 (c)
8 (c)
9 (b)
10 (b)
International Journal of Dermatology 2020, 59, 656–669