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A New Onychocryptosis Classification and Treatment Plan

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ORIGINAL ARTICLES

A New Onychocryptosis Classification and Treatment Plan

Alfonso Martínez-Nova, Lic Pod*

Raquel Sánchez-Rodríguez, Lic Pod*
David Alonso-Peña, MD*

Onychocryptosis is a pathologic condition of the nail apparatus in which the toenail dam-
ages the nail fold. It is a common condition provoking pain, inflammation, and functional
limitation. It principally occurs in the hallux. Onychocryptosis is one of the most frequent
complaints regarding the foot and accounts for many clinical consultations. The disorder
has been classified in terms of the stages of the pathologic condition. In our practice, we
discovered a clinical entity that was not previously classified in the literature. We classify
onychocryptosis into stages I, IIa, IIb, III, and the new stage IV. A treatment plan is offered
for each stage of this classification, with both general and specific indications given. In
onychocryptosis treatment, it is important to select the surgical technique best suited to
the patient’s particular clinical situation. (J Am Podiatr Med Assoc 97(5): 389-393, 2007)

Onychocryptosis is a pathologic condition of the nail
apparatus in which the toenail damages the nail fold.
It is a common condition that provokes pain, inflam-
mation, and functional limitation. It principally af-
fects the hallux, although it can also occur in the
lesser toes. Onychocryptosis is more frequent in men
(62%) than in women (38%). Although all age groups
are affected, most patients are adolescents in the
first and second decades of life.1 The fibular canal is
more often affected than the tibial canal, in a propor-
tion of 2:1.
The cause of the condition in childhood and adoles-
cence is usually rounded trimming of the toenails, cut-
ting with unsuitable instruments, or onychophagia.
Other conditions conducive to the condition are hyper-
hidrosis, wearing inappropriate footwear, direct trau-
ma, biomechanical alterations, pathologic curvature of
the nail plate, surgical iatrogenic conditions, excessive
weight, and the first toe being longer than the others.
Congenital onychocryptosis is an infrequent form of
presentation, believed to be due to intrauterine trauma
or hereditary transmission.2 Heifitz3 divided onycho-
cryptosis into three stages. Recently, Mozena4 refined
this classification, establishing four stages:
*Podiatry, Department of Nursing, University of Extre-
madura, Cáceres, Spain.
This article is a summary of the main part of Martínez-
Nova A: Podología: Atlas de Cirugía Ungueal, Editorial
Médica Panamericana, Madrid, 2006, and is adapted with
permission of the publisher.
Corresponding author: Alfonso Martínez-Nova, DPM,
Centro Universitario de Plasencia, Avda. Virgen del Puerto
nº 2, 10600 Plasencia, Cáceres, Spain.
• Stage I (inflammatory stage). This stage is
characterized by the presence of erythema, slight
edema, and pain when pressure is applied to the lat-
eral nail fold. The nail fold does not exceed the limits
of the plate (Fig. 1).
• Stage II (abscess stage). This stage is divided
into two substages. In stage IIa the pain increases
and there is edema, erythema, and hyperesthesia.
There may be serum drainage and infection. The nail
fold exceeds the nail plate and measures less than 3
mm (Fig. 2). Stage IIb has symptoms similar to stage
IIa. The hypertrophic fold exceeds the plate and
measures more than 3 mm (Fig. 3).
• Stage III. In stage III, the symptoms worsen,
with granulation tissue and chronic hypertrophy of
the nail fold. The granulomatous or hypertrophic tis-
sue largely covers the nail plate (Fig. 4). If onycho-
cryptosis is not properly treated, it may progress even
further, resulting in serious chronic deformation of
the toenail, nail folds, and distal fold.
We define a stage IV, which completes Mozena’s
classification. Stage IV results from evolution of stage
III, with serious chronic deformity of the toenail, both
nail folds, and the distal fold (Fig. 5). The difference
between stages III and IV is the distal hypertrophy.
Indications for Nail Surgery
Nail surgery is indicated when the patient has pain
and functional disability; in cases of recurrent ony-
chocryptosis, surgical relapse, or iatrogenic nail dis-

Celebrating 100years of continuous publication:1907–2007

Journal of the American Podiatric Medical Association • Vol 97 • No 5 • September/October 2007 389
Figure 1. Stage I onychocryptosis.
Figure 3. Stage IIb onychocryptosis.
Figure 5. Stage IV onychocryptosis. (Reprinted with
permission from Martínez-Nova.1)
orders; and when conservative treatments have failed.
The surgery should have several aims, with the over-
all objective of restoring the integrity of the nail appa-
ratus. The surgical procedure should correct the struc-
390 September/ October 2007 • Vol 97 • No 5 • Journal of the American Podiatric Medical Association
Figure 2. Stage IIa onychocryptosis.
Figure 4. Stage III onychocryptosis.
tural deformities of the nail, restore the longitudinal
trajectory of the nail plate, reestablish the morpholog-
ical and normal physiologic features of the nail folds,
prevent painful processes and infections, and con-
serve the biomechanical function of the nail plate.
The ultimate aim is to completely recover the func-
tionality of the nail apparatus.4
Discussion
In the medical, dermatologic, and podiatric medical
literature, various surgical techniques have been de-
scribed to treat onychocryptosis. The ideal surgical
procedure should result in a high level of patient satis-
faction (both functional and aesthetic), a rapid return
to normal activities, and a low rate of recurrence. Al-
though an attempt has been made to establish a “stan-
dard technique” that will resolve onychocryptosis in
most cases, there is no scientific evidence that any
single technique is the procedure of choice in all cases.
Celebrating 100years of continuous publication:1907–2007
 Despite this lack of scientific evidence for the su-
periority of any one technique, many studies5-8 have
shown greater success with the phenol-alcohol tech-
nique compared with other techniques. These studies
show high rates of efficacy (80% to 95%) and low recur-
rence rates (approximately 2% to 5%). On the negative
side is a 2- to 5-week recovery time,9 with the incon-
venience that this represents for the patient. More-
over, chemical matrixectomy may destroy too much
or too little tissue because it is not a precise tech-
nique. Many other variables can influence the effec-
tiveness of chemical matrixectomy, including tissue
hydration; bleeding, which can cause dilution of the
application; and the shelf life of the chemical used,
which can affect its concentration. Nonetheless, the
phenol-alcohol technique is clearly the most exten-
sively studied and practiced technique. It is simple to
perform, requires no complex instruments, has a
broad range of indications, and is widely endorsed in
the dermatologic and podiatric medical literature.
The phenol-alcohol technique can be performed in
the presence of concomitant infection,10 and Giaca-
lone11 demonstrated that it can be applied to diabetic
patients, for whom it presents no differences in heal-
ing time or postsurgical complications. The use of
sodium hydroxide, less prevalent in the podiatric
medical community, has the same advantages as phe-
nol, but with considerably less tissue destruction.12
Other studies, however, have found no significant dif-
ferences between mechanical resection of the matrix
and phenolization of the matrix.13 This last study rec-
ommends resection of the matrix to avoid the use of
a toxic substance such as phenol. Persichetti et al14
affirm that simple excision of the matrix using me-
chanical procedures (with a curet or scalpel) is most
effective, leading to fewer complications and infec-
tions and with a shorter healing time.
The use of physical methods to perform the ma-
trixectomy, such as carbon dioxide laser dissection
or electrodissection, have also been discussed.15, 16 Al-
though they are important and effective surgical
methods, they are relatively expensive.
Most of the reports we found in the medical litera-
ture were retrospective studies; only two were prospec-
tive. They consisted of randomized controlled clinical
trials comparing two techniques (phenol versus me-
chanical resection of the matrix with curet or scalpel).
One of these two studies suggests using the phenol
technique,15 and the other recommends mechanical
resection of the nail matrix.13 The findings differ be-
cause the aesthetic and functional results depend not
only on the technique used but also on the skill of the
professional, the recovery protocol, the appropriate
selection of the patient, and other factors. The podi-
Celebrating 100years of continuous publication:1907–2007
Journal of the American Podiatric Medical Association • Vol 97 • No 5 • September/October 2007
atric medical community must undertake scientific
studies and controlled clinical trials to obtain demon-
strable scientific parameters as part of evidence-
based podiatric medical research.17 It is important to
offer a surgical solution for each stage of onycho-
cryptosis, selecting the appropriate technique for the
patient’s particular clinical situation.
Treatment Algorithm According to the
Stage of Onychocryptosis
The surgical techniques used are classified into four
groups according to the stage of onychocryptosis
(Fig. 6).
Excision of the Spicule and Partial
Matrixectomy: Suppan I Technique
General Indication. Onychocryptosis affecting the
nail plate without hypertrophy of the nail fold. The
technique consists of excision of the affected portion
of the toenail and partial mechanical matrixectomy
(with curet or scalpel).18, 19
Indications According to Stage
• Stage I
• Adult or elderly patients, in whom tissue-regen-
eration capacity is reduced and likelihood of recur-
rence is lower.
• Patients with insulin-dependent diabetes. In pa-
tients with some vascular risk or poor control of their
diabetes, after previous stabilization of the vascular
situation and glycemia, this technique is preferred to
phenol-alcohol to avoid complications caused by the
burn.
Chemical Partial Matrixectomy:
Phenol-Alcohol Technique
General Indication. Onychocryptosis affecting the
nail plate with hypertrophy of the nail fold of less
than 3 mm. In these cases, excision of the portion of
affected toenail and phenol partial matrixectomy are
performed.20-22
Indications According to Stage
• Stage I
• Stage IIa
• Young or adolescent patients because they have
great tissue-regeneration capacity. The phenolization
ensures a low recurrence rate.
• Patients with controlled type 1 or 2 diabetes. The
phenol-alcohol technique is safe in diabetic patients
who have no vascular risk and good control of their
diabetes.
391
 Onychocryptosis

Stage I Stage IIa Stage IIb Stage III Stage IV

Erythema, slight Increased pain, Increased pain, Granulation tissue Serious chronic
edema, and pain. edema, erythema, edema, erythema, and chronic hyper- deformity of the toe-
hyperesthesia, hyperesthesia, trophy of the nail nail, both nail folds,
serum drainage, serum drainage, fold. and distal fold.
and/or infection. and/or infection.

Nail fold does not Nail fold exceeds Nail fold exceeds Granulomatous or Hypertrophic tissue
exceed the limits of the nail plate the nail plate hypertrophic tissue completely covers
the nail plate. < 3 mm. > 3 mm. widely covers the lateral, medial, and
lateral nail plate. distal nail plate.

Adults Young patients Aesthetic Young patients

Winograd with tibial/fibu-
Suppan I Phenol reconstruction
lar/distal
hypertrophy

Type 1 DM Controlled Winograd

Suppan I Type 1 or 2 DM
Phenol
Adults
Young Phenol total
patients matrixectomy
Phenol

Figure 6. Stage and treatment algorithm. DM indicates diabetes mellitus.

Wedge Resection of the Toenail and Nail Fold

Aesthetic Reconstruction Technique. General In-

dication. Onychocryptosis affecting the nail plate
with hypertrophy of the nail fold exceeding 3 mm.
These cases involve excision of the affected portion
of the nail plate, partial matrixectomy, and wedge ex-
tirpation of the hypertrophic nail fold and the nail
bed. The hypertrophic fold is cleared from the matrix
zone, below the eponychium to the distal end of the
toenail (Fig. 7). No cutaneous incision is made, and
therefore no stitches are required.23, 24
Indication According to Stage
• Stage IIb
Winograd Technique. General Indication. Ony-
chocryptosis affecting the nail plate with hypertrophy
of the nail fold greater than 3 mm. These cases in-
volve excision of the affected portion of the nail
plate, partial matrixectomy, and extirpation of the hy-
pertrophic tissue.25, 26 Figure 7. Wedge resection of the lateral fold using the
Indication According to Stage aesthetic reconstruction technique. (Reprinted with
• Stage III permission from Martínez-Nova.1)

Celebrating 100years of continuous publication:1907–2007

392 September/ October 2007 • Vol 97 • No 5 • Journal of the American Podiatric Medical Association
 Total Matrixectomy
General Indication. Onychocryptosis with dystro-
phy of the nail folds and distal folds. Nail dystrophy.
Nail excision and total matrixectomy with phenol is
performed.27-30
Indication According to Stage
• Onychocryptosis in stage IV adult patients
• Onychogryphosis, onychodystrophy
• Chronic hypertrophy of the distal and lateral folds
In this stage of our classification (stage IV), the lat-
eral and distal folds are considerably hypertrophied,
and the nail is affected. There are two treatment op-
tions. The first option is three Winograd procedures
for tibial/fibular/distal hypertrophy. This procedure is
indicated in young patients to conserve the integrity
and function of the nail apparatus. The second option
is phenol total matrixectomy, which must be per-
formed in adult patients. If other disorders are pres-
ent, such as onychomycosis or onychodystrophy,
phenol total matrixectomy might be the better option.
If the nail fold is widely affected, the Kaplan31 tech-
nique should be considered.
Conclusion
Correct management of onychocryptosis requires
identification of the stage and evaluation of the af-
fected tissues. Nail surgery should be considered in
cases of pain, recurrent onychocryptosis, surgical re-
lapse, and failure of conservative treatment. It is im-
portant to select the surgical technique that is best
suited to the patient’s particular clinical situation.
Financial Disclosures: None reported.
Conflict of Interest: None reported.
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