Acad Dermatol Venereol - 2010 - Becerro de Bengoa Vallejo - Total Nail Ablation For Onychodystrophy With Optimized Gauze

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x by Universidad Rey Juan Carlos C/Tulipan S/N Edificio, Wiley Online Library on [25/10/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
DOI: 10.1111/j.1468-3083.2010.03569.x JEADV
ORIGINAL ARTICLE
Total nail ablation for onychodystrophy with optimized

gauze–phenol application
R Becerro de Bengoa Vallejo,† ME Losa Iglesias,‡,* L Alou Cervera,§ D Sevillano Fernández,§
J Prieto Prieto§
†
Escuela Universitaria de Enfermerı́a, Fisioterapia y Podologı́a, Facultad de Medicina, Universidad Complutense de Madrid, Madrid,
‡
Facultad Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, and §Departamento de Microbiologı́a, Facultad de Medicina,
Universidad, Complutense de Madrid, Madrid, Spain
*Correspondence: ME Losa Iglesias. E-mail: marta.losa@urjc.es
Abstract
Background Nail disorders are frequent among the geriatric population and unfortunately, repeat avulsion
procedures often result in complications.
Objective To utilize a phenol-based total matricectomy technique for permanent nail ablation and evaluate its
effectiveness.
Methods We performed total nail ablation on 34 toenails of the hallux (30 patients) with a gauze–phenol
application technique and evaluated the degree of pain reported by the patient 12 months postoperatively compared
with the preoperative stage. Furthermore, we evaluated the patients’ satisfaction with the final cosmetic appearance
as well as their satisfaction with the overall procedure.
Results All patients reported ‘too much’ or ‘severe’ pain prior to surgery and 94.11% reported ‘no pain’ 12 months
post-surgery. A vast majority of the patients (82.35%) felt pleased with the cosmetic results and all patients reported
that they were ‘very satisfied’ or ‘strongly satisfied’ with the procedure when interviewed at their 12 month follow-up
examination.
Limitations There were a limited number of participants in this study across an extensive timeframe.
Conclusion Phenol-based total nail ablation with specific gauze application is safe, inexpensive and has a high
rate of patient satisfaction.
Received: 31 July 2009; Accepted: 15 December 2009
Keywords
matricectomy, nail ablation, onychodystrophy, phenol
Conflict of interest
None declared.
Introduction Onychogryphosis or Gryposis unguium is a severe deforma-

Nail disorders are frequent among the geriatric population. This is tion of the nails, most often involving the nails of the great toes.
in part caused by impaired circulation and in particular, suscepti- The involved nail becomes significantly thickened and curved,
bility of the senile toenail to fungal infections, faulty biomechanics, presenting a claw-like shape. This hypertrophy may be due to
neoplasms, dermatological or systemic diseases and associated trauma and ⁄ or permanent shoe pressure or neglected care.
treatments. With ageing, the rate of growth, colour, contour, sur- Gryposis unguium may also occur in patients suffering from
face, thickness, chemical composition and histology of the nail psoriasis, ichthyosis hystrix and other epidermal dysplasias.
unit change. Age-associated disorders include brittle nails, trachy- Often, repeat avulsion procedures are performed for treatment,
onychia, nail plate hypertrophy (onychauxis), pachyonychia, but unfortunately, a distorted curvature of the newly formed nail
subungual corns, onychogryphosis, onychophosis, onychoclasis, plate and an elongated, thickened nail caused by hypertrophy of
recurrent ingrown toenails (onychocryptosis), onycholysis, infec- the nail plate and the nail matrix are resulting complications.
tions, splinter haemorrhages, subungual haematoma, subungual When a nail becomes grossly misshapen and onychocryptosis
exostosis and malignancies. These disorders can occur through occurs, permanent ablation of the matrix is the best choice of
faulty biomechanics or trauma from wearing shoes.1,2 treatment.
ª 2010 The Authors

JEADV 2010, 24, 936–942 Journal compilation ª 2010 European Academy of Dermatology and Venereology
14683083, 2010, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1468-3083.2010.03569.x by Universidad Rey Juan Carlos C/Tulipan S/N Edificio, Wiley Online Library on [25/10/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Total nail ablation for onychodystrophy 937
When both margins of the nail have substantial ingrowth

because of a pincer nail, both sides can be treated simultaneously,
leaving a midline zone of nail. Ablation of the entire nail matrix is
an option in this situation and may be a preferable choice if treat-
ing both margins has the potential to leave a residual nail, which
is of no cosmetic value or will have a further tendency to result in
onycholysis.3 In this setting, there are studies that favour phenol-
based ablation, with success of this technique likely to be in the
order of 90%,4,5 with some studies reaching as high as 97%.6
Onychodystrophy is a common condition that may cause
intractable pain and discomfort in the foot, further aggravated by
wearing shoes, hindering normal walking and markedly decreasing
the quality of life of the patient. It can cause the patient to abstain
from many routine activities, such as walking and sports and may Figure 1 Aspect of the hallux nail in the preoperative stage.
also result in loss of work.7 The treatment options are varied and
range from conservative or non-operative care to different types of
matrix excisions based on the duration and severity of the symp- Pre-surgical screening
toms.8,9 Many patients require conservative treatment every 3 or The nail was subjected to direct microscopic examination with
4 months for nail trimming (reduction) with a strong dependency 10% KOH preparation and fungal cultures. Depending on the
on the physician to reduce the thickness of the nail as palliative results, appropriate anti-fungal and anti-bacterial medications
treatment. The ablation of the entire nail matrix is an option for were administered and that sample was excluded from the study.
gryposis unguium, ingrown nail and pincer nail deformity. A sin- Five patients were diagnosed with onychodystrophy and ⁄ or pincer
gle lateral margin is usually adequate for ingrown nails, even if nails with subungual exostosis. The diagnosis was achieved by pain
both sides of the nail are involved. The application of phenol for under compression of the toenail against the distal phalanx and
partial matrix removal has been widely documented in the litera- lateral and ⁄ or medial oblique X-ray.
ture and results have been almost uniformly in favour of phenoli-
zation reducing recurrence and improving overall results.10–14 We Surgical procedure
have recently described a gauze application approach for phenol- The hallux and nail was properly disinfected with 70% alcohol
based partial matricectomy15 as another technique that can be and povidone-iodine, and a local anaesthetic of 1% mepivacaine
used instead of the traditional cotton swab application approach. was injected using a hallux block. A digital tourniquet was applied.
In the current study, we describe the phenol gauze application The eponychium was released from the nail plate.
technique for use in a total nail ablation procedure. We have A straight haemostat was used to grasp the distal nail plate
performed this method of permanent nail ablation for a number which was then lifted upwards exposing the hyponychium, entire
of years and now report our experience. nail bed, proximal matrix until the posterior nail fold was reached.
The haemostat was clamped and gently turned away until the
Materials and methods offending nail was removed from under the proximal nail fold,
Institutional review approval for the study was obtained from the exposing the nail bed (Fig. 2). The proximal nail fold was excised16
Research Committee of the Complutense University and written using a #15 blade to eliminate the dorsal matrix that was the deep-
informed consent was obtained from all participants. est and most proximal part of the ventral proximal nail fold
(Fig. 3a,b).17
Patient recruitment Once the nail was removed and the proximal nail fold excised,
All patients diagnosed of onychodystrophy were informed of the any residual blood was first cleaned off with sterile gauze prior to
various treatment options: conservative care, partial matricectomy, phenol application to prevent blood coagulation. Once the clean
or permanent matricectomy using surgical or chemical permanent nail matrix was exposed, a piece of sterile gauze was rolled up at
nail ablation (Fig. 1). Diabetic patients and patients with vascular one end to form a pointed tip and dipped in a solution of 88%
disease were not included in the study. Often, the patient had been phenol. To reduce the risk of excess phenol contacting the
previously misdiagnosed and was treated with total nail ablation patients’ skin, the gauze tip was placed pointing upwards so that
or partial matricectomy by Winograd or Phenol techniques the phenol soaked into the dry gauze. The tip of the sterile gauze
followed by recurrence. was pressed onto the exposed area down to the proximal matrix
Four patients underwent bilateral nail removal and 26 patients, with the aid of a 2-mm-wide mini-osteotome, until it completely
unilateral. The bilateral patients underwent two separate surgeries, covered the entire zone of the matrix and the exposed nail bed
thus we refer to 34 surgeries, but 30 patients. (Fig. 4).15
ª 2010 The Authors

938 Becerro de Bengoa Vallejo et al.
(a)
(b)
Figure 2 The haemostat clamped the offending nail and is
turned away from the site of the ingrowth, exposing the nail bed.
This application was performed three times for 1 min each. The
nail bed appeared white due to tissue coagulation from the phenol.
Care was taken to prevent the phenol from coming into contact
with the skin by holding a gauze pad on the skin during the phe-
nol application. The tourniquet was then released, and the phenol-
soaked gauze remained in place for an additional 30 s to coagulate
any vessels that could potentially lead to bleeding.
After the phenol application procedure, 70% alcohol was used
to irrigate the exposed area for a period of 20 s both to dilute and
to wash out the residual phenol and the remaining alcohol was
removed with a sterile gauze pad (Fig. 5). The effectiveness of the
gauze–phenol application technique can be appreciated for total Figure 3 Isolation (a) and removal (b) of the dorsal matrix with a
nail ablation, with complete coagulation of the matrix and vessels 15 blade.
of the nail bed and no residual bleeding (Fig. 6).
Postoperative care wore a postoperative shoe for at least 5 days until they could com-
Postoperatively, the area was coated with an antibiotic ointment fortably wear a regular shoe. The final aspect of the total nail
and silver sulfadiazine18 in combination with 10% povidone removal can be appreciated after 20 days (Fig. 9). Once the nail
iodine was used as previously described (Fig. 7).19 The hallux was bed had healed, the patients were instructed to visit the clinic for
wrapped in sterile gauze and covered with an elastic auto-adhesive follow-up every 4 months until at least 12 months post-surgery.
bandage. For follow-up examination, the patients came to the In the elderly population, there are sometimes complicating medi-
clinic 72 h after surgery and every week until the nail bed was cal factors, raising concern over secondary bacterial infection. In
healed. Patients were instructed to keep the foot elevated as much these instances, flucloxacillin or similar was given for 7 days and
as possible and to refrain from ambulating for 24 h. Standard additional nursing supervision was considered for the wound.20
postoperative analgesia was prescribed consisting of acetamino-
phen (1000 mg) for pain. The patients were also instructed to Preoperative and postoperative questionnaire
keep the foot dry until the 72 h follow-up visit (Fig. 8). If at that After the procedures were concluded, all patients were asked to
point there were no complications, the patient could make a home complete a questionnaire for each surgery performed. We used a
treatment using povidone-iodine and silver sulfadiazine once a Likert Scale to assess pain pre- and post-surgery, cosmetic out-
day and cover with sterile gauze to avoid maceration. All patients come, and overall satisfaction with the procedure (questions 1–4).
ª 2010 The Authors

Figure 7 Silver sulfadiazine and 10% povidone iodine were

applied postoperatively.
Figure 4 Phenol-dipped gauze covering the exposed nail
bed.
Figure 5 After the phenol application procedure was complete,

70% alcohol was used to irrigate the exposed area.
Figure 8 Seventy-two hours follow-up visit.
An outside physician who had no involvement in the clinical care

of the patients evaluated the patients prior to surgery and at
12 months post-surgery as follows:
1 In the preoperative period, the degree of pain while wearing
shoes was measured with five graded categories of ‘severe
pain’, ‘too much pain’, ‘mild pain’, ‘little pain’ and ‘no pain’.
2 To determine whether the pain while wearing shoes had
improved 12 months after the operation, the same five
graded categories were used. Only responses of ‘no pain’
were considered a positive outcome.
3 To assess if the appearance of the hallux was cosmetically
Figure 6 After removal of the tourniquet, the effectiveness of acceptable, five graded categories of ‘strongly agree’, ‘very
the gauze–phenol application technique is apparent, with much agree’, ‘agree’, ‘disagree’ and ‘strongly disagree’ was
complete coagulation of the matrix and vessels of the nail bed
used. Responses of ‘very much agree’ and ‘strongly agree’ were
and no residual bleeding.
considered positive outcomes regarding cosmetic satisfaction.
ª 2010 The Authors

Table 2 Cosmetic satisfaction
Cosmetically acceptable 12-months follow-up

no. of patients (%
% total)
Strongly agree 28 (82.35)
Very agree 3 (8.82)
Agree 2 (5.88)
Disagree 1 (2.94)
Strongly disagree 0
Table 3 Overall patient satisfaction
Satisfaction 12-months follow-up

no. patients (%
% total)
Strongly satisfied 24 (70.58)
Very satisfied 10 (29.41)
Satisfied 0
Dissatisfied 0
Strongly dissatisfied 0
Figure 9 Twenty days post-surgery.
‘little pain’ (5.88%), but were improved considerably compared

4 To determine if the patient was satisfied with the overall
with their preoperative pain level (Table 1). We consider these
procedure, five graded categories of ‘strongly satisfied’, ‘very
results to be a positive outcome.
satisfied’, ‘satisfied’, ‘dissatisfied’ and ‘strongly dissatisfied’
A vast majority of the patients felt that the procedure left the
were used. Responses of ‘very satisfied’ and ‘strongly satis-
appearance of the hallux cosmetically acceptable 12 months after
fied’ were considered a positive outcome regarding overall
surgery (Table 2). In 33 out of 34 surgeries (97.05%), the patient
patient satisfaction.
responded between ‘agree’ and ‘strongly agree’ and only one
5 The patients were asked how many days of work or daily
patient marked ‘disagree’ (2.94%). Furthermore, all patients were
activities they had to miss for reasons of surgical recovery.
satisfied with the overall procedure (Table 3), including the one
patient who marked ‘disagree’ regarding the cosmetic result,
Statistics because the pain was alleviated.
Data were compiled and analysed using the SPSS Package (Version No patient required bed rest and all were advised to rest in a sit-
16.0; SPSS Inc., Chicago, IL, USA) and a chi-squared test was used ting position with their foot elevated. All patients could walk free
with a value of < 0.05 considered significant. of pain during the postoperative period using a surgical shoe. The
responses regarding loss of work or daily activity were reported as
Results a mean of 1.61 ± 0.64 days.
When we measured the degree of pain, the patient experienced Using this gauze–phenol application technique for total nail
while wearing shoes in the preoperative period, 30 patients ablation, 32 of 34 nails (94.11%) were successfully treated. The
(88.23%) had ‘severe pain’ and four patients had ‘too much pain’ complication rate in this series was two patients (5.88%) who had
(11.76%) (Table 1). The same measurement was taken after a superficial wound infections, which subsided with antibiotics and
period of 12 months to determine whether the pain while wearing subsequent healing was deemed satisfactory. These two patients
shoes had improved after the operation and we found that all had a small nail spicule from germinal matrix remnant because of
patients had satisfactory pain relief. In 32 surgeries, the patients the severe dystrophy of the toenail and prior ablation of the nail
had ‘no pain’ (94.11%) and in two surgeries, the patients had that perhaps made it difficult to reach the horn of the nail matrix
with the phenol. Both were re-operated using phenol as we
Table 1 Pain assessment described above and there was no regrowth. No complications
Degree of pain Preoperative no. of 12-months postoperative such as excessive bleeding or burns from phenol occurred and
patients (%
% total) no. of patients (%
% total) there were no total nail growth recurrences in any of the patients.
Severe pain 30 (88.23) 0
Too much pain 4 (11.76) 0 Discussion
Mild pain 0 0 Nail disorders comprise approximately 10% of all dermatological
Little pain 0 2 (5.88) conditions and affect a high percentage of the elderly.21 Pachyony-
No pain 0 32 (94.11)
chia and onychauxis (localized hypertrophy of the nail plate)
ª 2010 The Authors

manifest as hyperkeratosis, discoloration and loss of translucency the nail bed and removing both the lateral osteophytes and the
of the nail plate, with or without subungual hyperkeratosis.22 This distal dorsal bony tuft.23 When total matricectomy is performed
may be complicated by distal onycholysis, pain, increased suscepti- using a scalpel or CO2 laser, the proximal nail fold is dorsally
bility for onychomycosis, subungual haemorrhage and subungual reflected to allow full exposure of the nail matrix to prevent nail
ulceration.22 The gryposis unguium refers to enlargement and regrowth.45,46 Often during the postoperative period, patients can
thickening of the nail plate, which appears ‘ram’s horn-like’ or unfortunately experience significant pain, morbidity and pro-
‘oyster-like’, mostly involving the great toenail. The nail plate longed healing.44,47
appears uneven, thickened and brown to opaque, often with Although nail ablation and matricectomy can be achieved by a
multiple transverse striations and hyperkeratosis of the underlying number of medical and surgical techniques, we have found that
nail bed. The nail plate initially grows upwards and thereafter total matricectomy can be successfully and efficiently performed
deviates laterally towards the other toes, the direction of growth using phenol, thereby taking advantage of its haemostatic and
being influenced by pressure from footwear and matrix activity. anaesthetic effect. Our recently described gauze–phenol application
A few patients develop subungual gangrene because of pressure technique,15 applied for total nail ablation in the current study,
effects, especially in the presence of diabetes mellitus or peripheral allowed for destruction of desired tissue regions and haemostasis
vascular disease.1,23 without extensive tissue damage to either peripheral or deeper
The management of these conditions requires regular nail plate structures. The gauze technique has an advantage that allows for
trimming and foot care both for cosmetic reasons and for potential precise control over the duration of phenol application because
complications, such as subungual gangrene. Conservative manage- the entire surface area of the nail bed can be consistently treated.
ment is periodic partial or total debridement of the thickened nail The cotton swab approach, however, requires the clinician to
plate with the help of electric drills or burrs with removal of move the swab back and forth over the nail bed because of the
subungual hyperkeratosis and subsequent periodic trimming of the swab’s small surface area. In fact, applying phenol long enough
nail plate. For many people, including the elderly, it is very difficult and vigorously enough with the traditional cotton swab approach
to carry out these conservative management options on their own has a similar effectiveness to what we report with the gauze-based
and the patient often avoids walking or wearing shoes. Thus, we approach. In the current study, postoperative healing time was
agree with others that in such cases, permanent total nail ablation decreased and the desired cosmetic result was attained. Further-
is indicated for recurrent and troublesome onychauxis.1,22,24 more, patients achieved pain relief, a reduced risk of infection and
As a conventional treatment modality, partial or total nail abla- increased mobility over other methods.
tion has been widely used, but has resulted in high recurrence rates One advantage of surgical excision is the ability to obtain a his-
(42% to 83%).25–28 These procedures are remarkably invasive tological specimen to examine directly the anatomy of the matrix
surgical techniques with prolonged healing time, considerable pain and its removal, and the quick recovery time. This is in contrast to
and frequent postoperative infectious complications.5,26,28–34 potential results of a chemical burn that can arise from the tradi-
Permanent nail ablation via matricectomy is an effective means of tional phenol method. However, the two main drawbacks of surgi-
treating gryposis unguium and pincer nail deformity when cal excision are the associated pain and the lower success rate
conservative treatment has failed. Surgical techniques used to compared with phenol-based ablation methods. In our studies
destroy the nail matrix have included chemical ablation,35–37 surgi- using the optimized gauze–phenol approach, the patients did not
cal matricectomy via cold steel,38 Zadiks procedure,28 electrosur- report a level of pain that could not be controlled with standard
gery,39 and the CO2 laser.40 postoperative analgesia. Interestingly, we also observed that total
Complex surgical nail bed ablation procedures such as the nail ablation can abolish the pain from subungual exostosis.
Zadiks procedure41 are reported to have a relatively low relapse There are distinct advantages of this method over the previously
rate,27,28,42 but the cosmetic appearance can be disfiguring and described chemical approaches. First, we demonstrate a high cure
patients are often incapacitated to some degree for weeks after this rate or 95.11%, with a recurrence rate of only 5.88%. In all but
procedure. Furthermore, the recurrence rate when using chemical two cases, the nail matrix was permanently destroyed with no sub-
ablation is far better than that of the Zadiks surgical approach.43 sequent re-growth of the nail plate. In the two recurring cases, one
Leshin and Whitaker described the use of the CO2 laser to additional round of phenol treatment was performed to remove
achieve nail matricectomy for the treatment of pincer nail defor- the remnant nail, resulting in complete removal and cure. Second,
mity and reported the success rate to be 100% in their series of the postoperative care is simple and straightforward and patients
nine patients.44 Additionally, they noted no instances of infection can easily care for their lesions at home. As no sutures are used,
or prolonged draining.44 Joshua et al., also found the CO2 laser to there is no concern with associated surgical complications, such as
be an effective and simple method to allow decreased operative torn stitches. Additionally, post-treatment pain is minimal due to
time.40 The CO2 laser allows successful ablation of both the nail the anaesthetic effects of phenol and its ability to coagulate the
and matrix in addition to its inherent haemostatic properties. small sensory nerve. Furthermore, phenol also coagulates blood
Another technique that has been described involves an incision in vessels resulting in very little bleeding postoperatively compared to
ª 2010 The Authors

traditional surgical procedures. Finally, because patients can return 19 Dovison R, Keenan AM. Wound healing and infection in nail matrix
to their routine activities after 24 h, it is a very time-effective phenolization wounds. Does topical medication make a difference?
J Am Podiatr Med Assoc 2001; 91: 230–233.
approach. 20 Felton PM, Weaver TD. Phenol and alcohol chemical matrixectomy in
diabetic versus nondiabetic patients. A retrospective study. J Am
Conclusion Podiatr Med Assoc 1999; 89: 410–412.
21 Raja Babu K. Nail and its disorders. In Valia R, Valis A, eds. IADVL
In conclusion, toenail changes can result in severe pain and inter- Textbook and Atlas of Dermatology, 2nd edn. Bhalani Publishing House,
ference with daily activities, especially in the elderly population. Mumbai, 2001: 763–798.
Additionally, many patients are also concerned with the aesthetic 22 Cohen P, Scher R. Aging. In Hordinsky M, Sawaya M, Scher R, eds.
aspect of clinical conditions affecting the nails. The technique Atlas of Hair and Nails. Churchill Livingstone, Philadelphia, 2000: 213–
225.
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25 Greig J, Anderson J, Ireland A et al. The surgical treatment of
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ª 2010 The Authors


Acad Dermatol Venereol - 2010 - Becerro de Bengoa Vallejo - Total Nail Ablation For Onychodystrophy With Optimized Gauze

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Acad Dermatol Venereol - 2010 - Becerro de Bengoa Vallejo - Total Nail Ablation For Onychodystrophy With Optimized Gauze

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14683083, 2010, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1468-3083.2010.03569.

Total nail ablation for onychodystrophy with optimized

Introduction Onychogryphosis or Gryposis unguium is a severe deforma-

ª 2010 The Authors

When both margins of the nail have substantial ingrowth

ª 2010 The Authors

ª 2010 The Authors

Figure 7 Silver sulfadiazine and 10% povidone iodine were

Figure 5 After the phenol application procedure was complete,

Figure 8 Seventy-two hours follow-up visit.

An outside physician who had no involvement in the clinical care

ª 2010 The Authors

Table 2 Cosmetic satisfaction

Cosmetically acceptable 12-months follow-up

Table 3 Overall patient satisfaction

Satisfaction 12-months follow-up

‘little pain’ (5.88%), but were improved considerably compared

ª 2010 The Authors

ª 2010 The Authors

ª 2010 The Authors

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