ONYCHOCRYPTOSIS (UPDATE)

Nicole M. DeLauro, BSa and Thomas M. DeLauro, DPMb

a
Submitted while third-year student, New York College of Podiatric
Medicine, New York, NY

b
Professor, Division of Surgical Sciences, Professor, Division of Medical
Sciences, New York College of Podiatric Medicine, New York, NY

Proof and reprints to:

Thomas M. DeLauro, DPM

438 Arden Avenue
Staten Island, NY 10312-2323
(718) 984-5900
Fax: (718) 227-0990
E-mail: bellfoot@aol.com

1
Abstract

Onychocryptosis is prevalent globally, and most often the result of self-

attempts at curing the condition in its earliest stages. Its clinical presentation can

often be confused with a number of osseous and soft tissue abnormalities, some

of which have great import to a patient’s overall welfare. Treatment consists of

local and systemic care, including nail avulsion. Recurrences are reduced when

some form of matricectomy is utilized. Matricectomy techniques vary, and must

be selected on the basis of caregiver and patient preference. Although the

chemical matricectomy is popular, care must be exercised in selecting patients

for its use.

2
 ONYCHOCRYPTOSIS

Introduction

Onychocryptosis (also known as unguius incarnatus) describes the

puncture of periungual skin by its corresponding nail plate, resulting in a cascade

of foreign body, inflammatory, infectious, and reparative processes. Clinically,

these processes present as a painful, draining, often foul-smelling lesion of the

involved toe. Wound repair continues despite the presence of the offending nail

plate, causing an overgrowth of granulation tissue recognized as a pyogenic

granuloma. Soaks and prescription antibiotics lead to temporary improvement;

only removal of the offending nail portion results in a cure. The hallux nails are

most often involved, but lesser toenails can be involved also. On the hallux, the

tibial and fibular aspects appear to become involved with equal frequency, unless

a concomitant digital deformity places undue pressure on one nail border more

than another.

Unfortunately, the term “onychocryptosis” has been used interchangeably

with conditions that are less drastic, i.e., onychophosis, and incurvated nail

borders. Such usage is to be avoided, since it couples an erroneous diagnostic

picture with unsubstantiated therapeutic procedures.

The true incidence of onychocryptosis is unknown. The 1990 U.S. National

Health Survey asked questions regarding ingrown toenails, and reported that the

condition was more common with advancing age, in females, in those earning

less than $10,000 per year, and in those living in the Southern United States.

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Onychocryptosis was reportedly less common in African-Americans than

Caucasians in nearly all age groups reported. [1] In a pediatric dermatology unit,

Iglesias et al reported a 17 percent incidence of onychocryptosis in their young

population, but failed to describe which nail border or toe was most frequently

involved. [2] It is remarkable, however, that medical journal editors find it

necessary to publish at least one article per year on the topic. This suggests that

onychocryptosis is not only prevalent in the general population, but also that its

effective, nonrecurring treatment is challenging.

Pathophysiology

History and physical examination reveal improper nail trimming as the

most common etiology. Patients attempt to “round off” the corners of their

toenails, either for cosmesis or as a self-care effort when the nail edge is

incurvated. As a result of inadequate visualization and/or instrumentation, a barb

(much like that on a fishhook) is created. This barb anchors itself in the soft

periungual tissues, penetrating more deeply as the nail plate grows distally.

Ground reactive forces during ambulation, obesity, and pressure from

constricting footgear aid in this penetration. In the case of very long barbs and

spicules, a second puncture through the distal aspect of the toe occurs. If care is

still not sought and condition becomes chronic, local inflammatory processes can

lead to enzymatic digestion of the offending nail portion. Although this finally

permits healing, the accompanying pyogenic granuloma is so large that its

epithelialization results in permanent ungualabial hypertrophy. In the most

4
severe cases, this hypertrophy results in nail folds that grow over and obliterate

the remaining nail plate from view! In closed shoe gear and during ambulation,

these additional soft tissue masses create new pressures on the periungual

tissues, fostering recurrence of the original problem.

At least one author warns of the potential for osteomyelitis developing in

cases of chronic onychocryptosis [3], a fact to always be considered and not

overlooked.

Obesity, biomechanical disturbances, sports-related injury [4], and

hyperhidrosis reportedly increase the tendency for onychocryptosis [5, 6]. The

abducted gait and fuller proportions of an overweight person accentuate

pressures on the medial hallucal nail fold in particular. Abnormal foot

pathomechanics can lead to the development of skeletal deformities, e.g. hallux

abductovalgus, or abnormal pressure loads, either of which can force the nail

plate edge deeply into the skin. Pedal hyperhidrosis macerates and therefore

weakens skin integrity. In both types of patients, the slightest irregularity in the

nail plate edge easily becomes fixed to adjacent skin, setting the stage for

onychocryptosis.

Gunal et al. [7] cite a decreased incidence of onychocryptosis in barefoot

populations, pointing toward shoe gear as a possible etiology. Furthermore, their

paper investigated the incidence of onychocryptosis based upon hallux-second

toe length patterns. They found that patients with a second toe length equal to

or greater than the ipsilateral hallux length developed increased pressure on the

5
laterodistal hallux nail fold, resulting in an increased incidence of laterodistal

onychocryptosis. Based upon this concept, they successfully treated stage I

patients (the reader is referred to the section on Staging) with a simple toe

spacer in 17-22 days.

Differential Diagnosis

The workup for unguius incarnatus must include standard radiographs,

since a number of osseous and cartilaginous tumors may be causing nail plate

deformation and/or soft tissue impingement on the nail plate. The tumors to

consider include both benign and malignant lesions, such as true exostosis,

osteochondroma, enchondroma, chondrogenic sarcoma, and chondroid

syringoma. The cartilaginous cap of an osteochondroma is normally radiolucent.

The development of calcifications within this cartilaginous cap could signal

malignant conversion to chondrosarcoma; therefore, periodic radiographs and/or

consultation are strongly urged.

Neoplastic and nonneoplastic changes of skin also fall within the

differential diagnosis of onychocryptosis, particularly in recurrent cases or those

that are nonresponsive to conventional therapies. Bowen’s disease, basal cell

epithelioma, squamous cell carcinoma, malignant melanoma, glomus tumor,

digital angioleiomyoma [8], and Merkel cell tumor are to be considered. Glomus

tumors, often not visible to the naked eye, are characterized by their

paroxysmal, painful nature. Dependency of the limb or temporary occlusion of

superficial venous drainage both increases congestion within the glomus tumor,

6
thereby initiating a painful episode. As a result, either maneuver may help to

prove the presence of the lesion.

When subungual, squamous cell carcinoma can be especially aggressive,

leading to a fungating mass that engulfs the entire toe (Figure 1). Despite this

behavior locally, the lesion’s metastatic potential is low.

Subungual melanoma (also referred to as a melanotic whitlow), on the

other hand, can be both locally destructive and highly metastatic. In the absence

of acute trauma, subungual pigmentation that does not move distally as the nail

plate grows, pigmentation that “spills” onto adjacent nail folds, and

periungual/subungual ulceration are highly suggestive of malignant melanoma.

In this region, the acrolentiginous form of melanoma is most commonly

encountered.

Merkel cell tumor has masqueraded as granulation tissue on a teenager’s

toe. [9] These cells originate in the basal layer of the epidermis, and most often

cause pink or blue-black neoplasms on the head or neck of elderly patients.

Obviously, this reported case was unusual because of the tumor’s location and

the patient’s youth. Amputation at the first metatarsophalangeal joint was

performed, since metastases frequently occur. Tissues that can resemble

granulation tissue also include (in addition to this reported case of Merkel cell

tumor) pyogenic granuloma, squamous cell carcinoma, eccrine poroma, and

Kaposi’s sarcoma.

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 Subungual and/or periungual metastasis of primary cancer, resembling

the clinical picture of onychocryptosis with paronychia or pyogenic granuloma,

has been reported. The forty cases documented to date had the following organs

primarily involved (in decreasing order of incidence): lung (14 patients),

genitourinary tract (10 patient: six involving kidney, two involving the testes, and

one each involving the bladder and uterus), breast (5 patients), melanoma (4

patients), colon/rectum (2 patients), parotid gland (2 patients), sarcoma (2

patients), and larynx (1 patient). [10]

Recently, a case of recurring ingrown toenails in a fourteen-year-old on

cyclosporin therapy was reported. [11] The immunosuppressive drug was being

used to treat severe aplastic anemia. While taking cyclosporin, seven episodes of

onychocryptosis occurred. Once therapy was discontinued, no further ingrowing

developed. A causal relationship between cyclosporin and ingrown toenail was

suggested, and supported by the fact that epithelial overgrowth had been

reported in dogs taking cyclosporin. Experimentally, this overgrowth began seven

weeks after initiating cyclosporin therapy.

Onychocryptosis has also been described in patients undergoing

antifungal therapy with oral terbinafine. Weaver and Jesperson [12] suggested

that since the healthy nail plate was now adhering to the nail bed, ingrowing was

more commonplace. In another report, Connelley et al [13] theorized that

onychocryptosis might be secondary to the development of thinner, less friable

nails and the increased nail growth rate witnessed in treated patients.

8
 Ingrown toenails can be encountered in infants also, usually secondary to

one of three possible etiologies: congenital malalignment of the toenail, distal

imbedding with a normally directed nail, and congenital hypertrophy of the

lateral or distal nail fold. [14] Congenitally hypertrophied nail folds usually

respond to conservative treatment alone, since the ingrown toenail

spontaneously resolves as the child matures.

Staging

Patients that present with onychocryptosis may be placed into one of

three stages based upon clinical presentation. [5] In stage I lesions, the nail

plate has just begun to puncture the skin producing some discomfort and

excessive sweating locally. Stage II lesions (Figure 2) exhibit pyogenic

granuloma formation and are accompanied by seropurulent discharge and foul

odor. Stage III lesions resemble stage II, with the addition of epithelialized

granulation tissue.

Therapeutic Methods

Therapeutic decision-making should be based upon the patient’s stage of

involvement. While all three stages require resection of the offending nail

portion, stage II patients must undergo eradication of the pyogenic granuloma.

Stage III patients benefit from excision of the epithelialized granuloma, in order

to avoid future pressure from the now-hypertrophied ungualabium.

Numerous authors have previously described the classic techniques for

each of the above treatments. [15, 16, 17] Rather than repeating those

9
descriptions, the following pages intend to discuss published and experiential

concerns relative to the individual aspects of each therapeutic method. Hopefully,

this approach will meet the needs of both seasoned and beginning clinicians.

Systemic antibiotics and soaks as the sole therapeutic measure.

Nonpodiatric health care providers often employ this regimen, particularly in

stage I lesions. It is often quite effective in relieving initial drainage and

discomfort. Unfortunately, clinical improvement is short-lived (only two to three

weeks) and the patient inevitably progresses to a more advanced stage of

involvement. Such therapy is useful when the patient cannot be seen

immediately and even then only as a stopgap measure. In all other situations,

however, their use as the sole therapy are not recommended.

Nail plate removal: proportions, location, and aftercare. When the

cryptotic nail portion is located at the distal most portion of the nail fold, simple

removal via a slanted approach is all that is required. The remaining nail edge is

then curetted to remove any remaining barbs. Recurrence is unlikely with proper

subsequent nail trimming, or easily avoided by repeating the same procedure at

regularly scheduled intervals or when symptoms initially return.

The more common presentation, though, are patients who have already

attempted self-removal of the cryptotic nail portion using a variety of household

implements. Invariably, they succeed only in creating a new nail edge barb that

anchors itself in the soft periungual tissues at the middle or proximal third of the

nail plate. The “slant back” procedure described in the previous paragraph

10
renders only temporary involvement, necessitating removal of the entire nail

plate edge up to and including its root in the nail matrix (colloquially referred to

as the “straight back” procedure).

In these latter procedures, understanding the location and proportion of

the nail plate to be removed becomes paramount. An excessively conservative

degree of removal is ineffective, since the remaining nail plate edge of often

incurvated and vulnerable to a new episode of adjacent skin puncture. Overly

aggressive nail plate removal, while effective, is cosmetically unacceptable to

most patients.

If one recalls that, when viewed on end, the nail plate is relatively flat, the

location for splitting the nail plate prior to excision is easily identified. This

location is the juncture between the flat central portion of the plate and the

curved lateral portion. When this guideline is used, the results are both

cosmetically acceptable and successful in preventing recurrence.

There is one situation, however, when this axiom is difficult to apply: the

severely incurvated or “pincer” type nail plate. In these patients, only the most

central portion of the nail plate is flat. Removal of the tibial and fibular nail plate

borders (which is most often required because the excessive curvature results in

onychocryptosis of both edges) leaves only a thin sliver of remaining nail plate

(Figure 3). Cosmetically, total nail plate removal is the better choice. In the cases

where concomitant matricectomy is not performed, some might argue that nail

regrowth may result in a flatter, asymptomatic nail plate. If the original

11
deforming forces have not been corrected, this possibility would seem remote;

however, to the author’s knowledge no prospective studies have ever been

performed to prove or disprove that hypothesis. Speaking from a purely

experiential view, the early postoperative weeks do demonstrate a dramatic

flattening of the subungual soft tissues following total nail plate removal. Before

the procedure, these tissues had formed a palpable ridge beneath the pincer

nail.

A variety of instruments are used to split the desired portion of the nail

plate. The author assumes that the reader is well versed in their use, and

therefore will not review them here. Experience has taught, however, that the

selected instrument must (a) have jaws thin enough to pass beneath the nail

plate without lacerating the nail bed, and (b) be strong enough to split the nail

plate under treatment. Working in a distal-to-proximal fashion, the entire

exposed portion of the nail plate (i.e., up to the proximal nail fold) should be split

in a single motion rather than splitting the plate in a piecemeal fashion. The

latter technique only splinters the plate, producing any number of small barbs,

since it is technically difficult to hold the instrument in exactly the same plane

each time it is moved more proximally along the plate.

When the proximal nail fold is reached, selecting a thinner, chisel-bladed

instrument is more advantageous than continuing with the nail-splitting one. The

jaws of the nail splitter are almost always too large to fit beneath the proximal

nail fold without tearing it, and are too heavy for the tapered, feather-like edge

12
of the nail plate’s root. Narrower chisel blades are preferred, since they tend to

lacerate the nail bed and matrix less than wider blades, resulting in decreased

hemorrhage within the operative field, and less potential for creating a tract to

the very closely underlying distal phalanx. This tract allows cauterants (e.g.,

phenol) to leak through the tissues to the periosteum, eliciting an intense local

inflammatory response with prolonged pain, morbidity, and potential bone

necrosis. Even when tourniquets are used, the maintenance of a relatively

bloodless field is vital to a successful postoperative course.

Once the desired portion of nail plate has been removed, it is wise to

examine its proximal portion. Firstly, the proximal edge should be thin and

flexible, as found in a feather’s edge. Secondly, the proximal aspect of the

resected nail plate should be straight and complete, indicating that the entire

portion intended for removal was indeed removed. These simple maneuvers can

easily be overlooked, resulting in a poor cosmetic and functional outcome.

The undersurface of the proximal nail fold is the next area to be

inspected. As the nail plate is being avulsed, a thin membranous layer of

epithelium becomes partially detached either from the nail fold or the

eponychium (Figure 4). Unless removed, this membrane becomes adherent to

the nail bed and other periungual tissues, obstructing the outflow of serum or

blood postoperatively. As the reader is certainly aware, the intracutaneous

pressure developed by the enlarging seroma or hematoma can result in

disproportionate pain and even gangrene of the nail fold. The potential for tissue

13
necrosis is enhanced in patients with compromise of the microcirculation, e.g.,

diabetes mellitus.

Simple nail plate avulsion without matricectomy should require no more

than approximately one week of daily wound care. Although toenails ordinarily

require 12 months for full regrowth, patients should be advised to return in

approximately four to five months postoperatively for inspection of the regrowing

nail. At this interval, the advancing nail edge is just beginning to abut against the

periungual tissues. The edge should be curetted free of barbs, and cotton

inserted beneath the free nail plate edge to protect the soft tissues from

repuncture and to delay development of another incurvated nail border (the use

of cotton collodion insert to treat the initial phases of onychocryptosis has

already been described [18]). In the senior author’s experience, missing this

appointment usually leads to the patient’s having another experience with

onychocryptosis. In total nail plate avulsions without matricectomy, the same

concern exists since weight bearing and shoe gear force the distal subungual

tissues dorsally. The entire distal edge of the regrowing nail plate will eventually

abut the dorsally displaced soft tissues, causing discomfort. Prophylactically,

these patients should be reappointed at the initial signs of discomfort so the free

nail edge can be curetted and cotton inserted beneath it.

Matricectomy. Patients elect this option largely to minimize the incidence

of recurrence. The term “minimize” must be emphasized, since guarantees are

difficult, it not impossible, to deliver (Figure 5). Even the most successful

14
procedure does not protect a new nail edge from deformation in subsequent

years, especially as patient compliance (e.g., in the wearing of functional

orthoses to control deforming forces, etc.) decreases.

Caution should also be exercised in certifying that the prevention of nail

regrowth will be permanent. The nail bed and matrix are, in actuality,

microscopic structures whose borders are invisible to the naked eye. Their total

chemical destruction or surgical excision are therefore highly educated estimates

rather than precise techniques. Regrowth can occur, so practitioners must offer

realistic percentages regarding success. This is especially pertinent in total

matricectomies, when a thick keratotic layer develops over the nail bed

postoperatively. This layer does not resemble a nail plate histologically, and it is

dissatisfying to the patient in terms of its feel and appearance (Figure 6).

A variety of matricectomy techniques have been described, each falling

readily into one of several categories: chemical, electrosurgical, radiowave,

cryotherapeutic, lasing, nail abrasion, or excisional (the latter are also colloquially

referred to as “cold steel” procedures). Detailed explanations of each method

may be found in the references cited below. Some comments can be offered,

however, on the status of each technique and their subtleties.

Chemical , Electrosurgical, Radiowave, Cryotherapeutic, Lasing or Nail Abrasion

Techniques

15
 The most popular chemical matricectomies employ either phenol or

sodium hydroxide as the cauterizing agent. Each requires an absolutely bloodless

field, since free hemorrhage only dilutes the cauterant and absorbs the brunt of

its action, leaving little to no chemical remaining to affect the matrix. If

application is controlled (i.e., by precisely dripping phenol via a syringe, [19] or

through the use of fine-tipped cotton applicators), protection of adjacent skin

and irrigation are unnecessary. Cauterants used for a fixed time interval or

number of applications is favored by many, but these methods do not take into

account decreasing shelf-life and biologic potency. Instead, cauterant use should

end when the tissues under treatment assume a predetermined white or gray

hue. Although subjective, this approach aims for a more constant effect, rather

than a fixed-time technique that does not account for depth of individual tissues,

thickness, etc. Curettage after phenolization reportedly increases the procedure’s

effectiveness. [19]

While electrosurgical and radiowave [20] techniques employ

electromagnetic energy to cauterize tissue, lasing utilizes light energy within

specific wavelengths to thermal injury to the area under treatment. Similar to the

chemical methods, the depth and penetration of matrix destruction is imprecise,

potentially leading to periostitis, osteonecrosis, or chronic ulceration since the

distal phalanx sits only a few cell layers away.

16
 Some clinicians advocate the use of cryotherapy [21] to destroy nail

matrix tissue. This technique has not been uniformly successful, and is therefore

included for historical interest only.

Lasing of nail matrix to avoid recurrence also has its advocates. Serour

describes success using a carbon dioxide laser, [22] but warns that two-border

procedures and locally infected preoperative sites both result in an increased

incidence of recurring nail spiculization after lasing.

One final aspect of these techniques deals with their aftercare. The

techniques themselves create draining burn wounds that often require weeks to

heal. In addition to serous fluid, the drainage is supplemented by cauterized

tissue that has sloughed and is being ejected from the wound. Measures to

promote drainage and prevent occlusion are therefore essential.

Removal of the epithelial membrane encountered at the proximal nail fold

(as mentioned in the section above on nail plate removal) is one such measure.

Others include the use of 20% ferric chloride postoperatively (presumably

because this solution induces thrombosis), [23] continuous evaporating wet

dressings in the early postoperative period, and frequent (at least daily)

scrubbing and irrigation of the wound once the wet dressings have been

discontinued. In the author’s opinion, wet-to-dry dressings permit coagulation of

serum with resultant occlusion of drainage. Wound scrubbing and irrigation, both

of which are performed by the patient, maintain an exit portal for serum and

wound debris and are continued until the wound is completely dry. At times,

17
compliance with this regimen may be less than ideal, mandating the need for

curettage of the wound. In this setting, the single most reliable indicator of

inadequate drainage is increasing pain, caused by increasing intracutaneous

tissue pressure. As described earlier, the failure to recognize this development

can result in frank necrosis of an entire nail fold.

An interesting nonexicisional technique is that of nail plate abrasion. [24]

Since it does not attempt to destroy germinative tissue, the procedure is free of

the postsurgical considerations discussed in the preceding paragraph. Simply

stated, nail abrasion involves the thinning of nail plate with an electric grinder to

the point where it becomes flexible. This flexibility permits incurvated borders to

assume a more normal shape. When grinding, the most proximal and distal

aspects of the nail plate are preserved. The results depicted in the original article

are quite convincing, and deserve further study.

Another attempt at preventing recurrence without matricectomy is that

recently described by Aksakal et al. [25] In this study, fourteen patients

underwent a “straight back” partial nail avulsion without excision of hypertrophic

granulation tissue. Postoperatively, each patient applied silicone gel sheeting

continuously for four months. One year after surgery, twelve of fourteen patients

did not have a recurrence of onychocryptosis.

Excisional Techniques

Excisional techniques have been well described in prior publications and

are recognized by their familiar eponyms: Winograd, Frost, Zadik, Kaplan,

18
Steinberg trephine, and Suppan. Each involves sharp subtotal or total excision of

the nail matrix and, depending upon the procedure, the nail bed as well. Rather

than redescribing individual procedures, this section will deal with particular

aspects of the group as a whole.

Since excisional matricectomies are performed well into the subcutaneous

tissue, adequate depth of removal is not a matter of concern. Excisional

matricectomies are, however, somewhat unpredictable regarding the width of

matrix/nail bed removal. This is especially true at the most lateral and medial

margins of the nail matrix, which may not be encompassed within the surgical

margins. In such instances, a typical uneventful postoperative course is

interrupted several weeks or months later by the patient’s complaining of

increasing pain and inflammation at the proximal nail fold. This is almost always

due to regrowth of a nail spicule from the remaining matrix. At this point, a Frost

procedure readily identifies both the spicule and matrix to be removed. Patients

should therefore always be warned that a subsequent procedure is a possibility.

Some excisional procedures remove the nail matrix by splitting the

proximal nail fold into dorsal and plantar halves (e.g., Suppan), with the plantar

half containing the matrix. While often successful, this technique can strip the

dorsal half of its blood supply, resulting in necrosis and slough. Despite this

development, the potential for wound healing is high, resulting only in a longer

nail bed surface. As in the preceding paragraph, preparation of the patient for

this potential complication can save one from an otherwise unpleasant situation.

19
 Necrosis of the proximal nail fold can also result from an enlarging,

unrecognized hematoma following excisional matricectomy. This risk increases

then the remaining proximal nail fold is sutured to the exposed nail bed since

spontaneous evacuation of the hematoma is prevented. Increasing pain, edema,

tension at the suture line, and balloting of the proximal nail fold all point to the

diagnosis.

Suturing in the presence of remaining nail plate poses another technical

consideration. Some clinicians favor puncturing the nail from below upward

because of its ease, while others offer the same rationale for carrying suture in

the reverse direction. Theoretically but never proven, the latter choice does seem

to harbor a greater potential for transmitting superficial microorganisms into

deeper tissue. A final approach is that preferred by the senior author of not using

suture through nail plate at all. Generous nail plate avulsion and/or proper

incision planning should result in a requirement for sutures only in soft tissues or

at the ends of the incision. The central portion of the incision can then be closed

using sterile adhesive strips.

A seemingly extreme excisional approach was recently reported by Umeda

et al, and referred to as the nail bed-periosteal flap. [26] Following partial nail

avulsion and partial matricectomy, these clinicians raised a flap consisting of nail

bed and periosteum, inserting the lateral nail fold between the flap (which was

now superior to the nail fold) and the phalanx (now inferior to the nail fold).

20
 Numerous comparisons have been made between chemical and excisional

matricectomies. [27,28,29,30,31,32] Each study comes from centers outside the

United States, and cites the superiority of chemical matricectomies. At least one

report includes a follow-up period of only six months. The potential for disaster

with phenol matricectomy is illustrated by Sudden et al, [33] who discuss the

case of a hallux amputation in a fifteen-year-old boy following an extensive

phenol burn. In patients with any degree of arterial compromise, making certain

that digital perfusion is adequate is mandatory. Toe pressures less than 40 mm

Hg, or transcutaneous oxygen pressures (TcPO2) less than 30 mm Hg equate

with nonhealing wounds, and contraindicate these procedures.

Summary

Onychocryptosis is prevalent throughout the world and most often the

result of self-attempts at curing the condition in its earliest stages. Its clinical

presentation can often be confused with a number of osseous and soft tissue

abnormalities, some of which have great import to a patient’s overall welfare.

Treatment consists of local and systemic care, including nail avulsion.

Recurrences are reduced when some form of matricectomy is utilized.

Matricectomy techniques vary, and must be selected on the basis of caregiver

and patient preference.

21
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 FIGURE LEGENDS

Figure 1. This aggressive subungual squamous cell carcinoma has engulfed

the entire hallux. More subtle presentations could be confused with the

benign pyogenic granuloma.

Figure 2. An example of stage II onychocryptosis. Note the pyogenic

granuloma and associated paronychia.

Figure 3. This is an example of an incurvated nail, which is not to be

confused with true onychocryptosis. Partial nail avulsions would leave only a

thin central nail plate.

Figure 4. After partial nail avulsion, this proximal nail fold membrane must be

excised to allow unrestricted wound drainage.

Figure 5. This photograph of prominent, aberrant nail spicules illustrates the

difficulty in ensuring that nail regrowth will not occur following matricectomy.

Figure 6. This patient underwent a total matricectomy. Notice how the nail

bed continues to produce a thick callus, much to the patient’s dismay.

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