An ingrown nail affecting the fibular sulcus of the left hallux
A longstanding presentation affecting both sulci of both hallux nails
NB This page is from the 2005 Hyperbook.
Last evidence check January 2005.
An ingrown nail (onychocryptosis) occurs when the edge of the toenail digs into, and pierces, the skin adjacent to the nail. The skin may present as inflamed, swollen and is almost always tender. Opportunistic infections can occur from the normal skin flora. Infection always exacerbates the lesion as further swelling gives rise to further pressure and a likelihood of increased penetration of the nail.
The debilitating effects of an ingrown nail must never be underestimated. One of the first papers published on the operative management captures the sentiment well. “One of the most painful and incapacitating conditions encountered in the field of minor surgery, which can be relieved with gratifying results by proper surgical treatment, is the ingrown toenail” (Winograd 1929)
Studies in the United Kingdom have shown a 2:1 male to female ratio, most commonly affecting patients aged 16-25 years old (Langford 1989). In the USA the 1990 National Health Survey showed a 2:1.5 male to female ratio for patients younger than 45 years old; with increasing age more female patients suffered. Over 75 years of age the male to female ratio reduced to 1:1.6. (Levy 1992).
Ingrown nails have been reported to occur for a variety of reasons:
(Lloyd-Davies 1963).
Langford (1989) concurred with Lloyd-Davies but also included:
Diabetic patients have been found to have a higher incidence of ingrown nails compared with non-diabetic patients (Riviera 1998).
Ingrown nails have been reported to occur secondary to medicinal intervention. Patients with HIV infection, being treated with protease inhibitors have presented with multiple ingrown nails. Indinavir is the main protease inhibitor that has been implicated (Bouscarat 1998, Alam M 1999, Bourezane 1999). The immunosuppressive drug, Cyclosporin has been associated with the development of ingrown nails (Olujohungbe 1993). Similarly oral antifungal treatment has been associated with ingrown toenails (Connelly 1999), (Weaver and Jespersen 2000).
Most patients present with pain, swelling and difficulty with shoewear. All patients should be asked about possible underlying causes of chronic infection, such as diabetes and steroid use.
The foot should be examined for mechanical factors which might precipitate nail pressure or infection. Inspect the shoes – they may be the main source of pressure. Look for tenderness in the pulp or proximally, which may indicate osteomyelitis.
Differential diagnosis includes subungual exostosis, primary osteomyelitis of the phalanx and tumours of the nail bed, including subungual melanoma.
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An ingrown nail affecting the fibular sulcus of the left hallux |
A longstanding presentation affecting both sulci of both hallux nails |
There is no consensus on the classification of the lesion at presentation. The most frequent classification quoted in the literature is that first proposed by Heifetz (1937) and subsequently used by Mogensen (1971).
Infection and suppuration is more marked in grade 3. Untreated ingrown toenails can have serious and limb threatening consequences. Cox and Jones (1995) reported development of osteomyelitis as a consequence of chronic ingrown toenails. Tumours, primary or metastatic, can mimic the presentation of an ingrown toenail (Goldenhersh 1992, Requena 1993, Lemont 2002).
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To avoid ingrown toe nails, it is advisable not to cut the nails too short. Patients often believe that it is best to cut toe nails ‘straight across’, this would leave sharp corners of nail which could possibly cut into the adjacent toe. The correct advice would be to cut the nail following the outline of the end of the digit ensuring that when cut the whole of the leading edge of the nail is still visible. See Fig 3. It is preferable to use nail clippers rather than scissors. Scissors have a slicing action which can be painful. In patients who are not confident using sharp instruments, the nail can be shortened using an ‘Emery board’ or abrasive file.
Conservative treatment is indicated for all grade 1 presentations and some grade 2. Treatment is restricted to debridement of the affected nail. Some practitioners pack the affected sulcus with cotton gauze; as described by Reijnen and Goris (1989).
If interdigital pressure appears to be an aggravating factor, the use of an interdigital spacer has been reported as successful (Gunal 2003).
Antibiotics are often prescribed for infected ingrowing toenails. While this may be appropriate to control acute symptoms, patients often have further problems and antibiotics should not be seen as a long-term solution. Reyzelman et al (2000) showed that periprocedural antibiotics did not improve the outcome of phenol matricectomy, even if given a week before to allow the infection time to resolve before the main procedure.
Surgical treatment is indicated in all grade 3 presentations and some of the worst grade 2 presentations. It may also be indicated in other nail conditions which present with discomfort or pain:
Patients must be assessed to ensure adequate blood supply to ensure wound healing. Physical signs of ischaemia include absent posterior tibial and dorsalis pedis pulses, slow capillary filling time, skin atrophy and absence of skin hair. Patients with an ankle brachial index below 0.5 or toe pressures below 40mm Hg are at risk of non-healing (Giacalone 1997).
In most cases patients do not require laboratory testing prior to nail surgery (Siegle 1992). If a subungual exostosis or bony abnormality is suspected, plain film radiographs are indicated. Radio-isotope studies may be useful if osteomyelitis is suspected, especially in chronic ingrown nails (Cox 1995). Subungual glomus tumours can be detected with magnetic resonance imaging (Holzberg 1992).
A local anaesthetic ring block technique is all that is required for routine toenail surgery. Sedation and general anaesthesia is reserved for uncooperative patients or the very young (Dixon 1983, Murray 1989). Lidocaine or bupivicaine is generally used. Bupivicaine has a longer duration of action and therefore provides greater postoperative pain relief. Vasoconstrictors, such as epinephrine, must be avoided in extremities.
A variety of procedures have been advocated. Some procedures require full surgical theatre facilities, where as others can be performed in a clean clinical setting following aseptic techniques.
In Winograd’s original paper he reported no recurrences of the ingrown nail. Later studies have reported recurrence rates of between 11% and 27% (Keyes E 1934, Murray and Bedi 1975, Issa et al 1988, Van Der Ham et al 1990).
Zadik reported no recurrences but 2 cases of postoperative necrosis. Further studies of this technique have reported recurrence of nail spicules at a rate from 27% to 50% (Townsend and Scott 1966, Murray and Bedi 1975, Palmer and Jones 1979).
The Symes procedure has reported postoperative spicules. Thompson and Terwilliger (1951).
Two chemical have been described in chemical ablation of the germinal nail matrix; sodium hydroxide and phenol (Travers and Ammon 1980). The use of phenol is most commonly reported. Reports of phenol use occur as early as 1901 with Porter, and Boll introduced this technique formally in 1945. This procedure has lower recurrence rates, reports range from 3.9% to 10% (Morkane et al 1984, Issa and Tanner 1988, Van Der Ham et al 1990, Mori et al 1998, Herold 2001).
A number of RCTs have compared surgical techniques. Greig (1991) found a 73% recurrence rate after both total nail avulsion and wedge excision of the nail, but only 9% after phenol matricectomy. Simple avulsion of the whole nail or a wedge should not not be a standard treatment; if surgery is necessary the germinal matrix should be ablated at the first procedure.
Other trials (Issa + Tanner 1988, Herold 2001, Gerritsma-Bleeker 2002) have compared surgical and chemical matricectomy. Recurrence rates were similar, although there was a trend for less revision surgery after chemical ablation. Combined surgical and chemical matricectomy was found by Issa and Tanner to have fewer recurrences than either surgery or chemical ablation alone, and this is the technique we use.
Recurrence rates with phenol matricectomy are low, but nail spicules have occurred following this procedure. The main complication can be superficial chemical burns. There is one reported case of amputation of the distal phalanx of a big toe following a chemical burn induced during nail surgery (Sugden and Levy 2001).
This review has examined the current evidence surrounding the incidence and treatment for ingrown toe nails. Stage 1 and some Stage 2 presentations can be managed with conservative measures. Some Stage 2 and all Stage 3 presentations are best managed surgically. Of all the procedures available for surgical management, phenol matricectomy, possibly combined with surgical matricectomy appears to offer the best results.