Ingrowing toenail or also known as onychocryptosis is a condition when the distal border/ margin of the nail plate begins to grow into the lateral fold of the nail (lateral nail fold). The ingrowing toenails will later lead to irritation, inflammation and in a worst case scenario may lead to fungal and bacterial infection.
Ingrowing toenail will undergo 3 different stages that begin with inflammation/ stage 1. On stage 1 the lateral nail fold appears to be tender, erythematous and slight edematous. This will follow by stage 2 or known as formation of the abscess where the tenderness, edema and erythema are getting worse and serous and purulent discharge are noted. The final stage (stage 3 / formation of granulation tissue) consists of granulation tissue and tenderness edema and erythema at the lateral nail fold. Ingrowing toenail is a recurring process.
Generally ingrowing toenail can be prevented with proper trim the nail and wear a a properly fitting shoe.
In terms of epidemiology, ingrowing toenail mostly affects men than women around the age of 16 - 25 years old. However ingrowing toenail is more common in women than men when they get older. It typically affects the lateral edge of the nail rather than the medial edge of the nail with great toenail is mostly affected. People with low income are more prone to develop ingrowing toenail. The prevalence of the ingrown toenail is 24.5 per 1000 individuals and 50 per 1000 individuals are people aged 65 years and above.
The risk factors for developing ingrowing toenails are mainly a genetic factor which leads to a decrease in nail thickness, increased in nail fold width and medical rotation of the toe. Other factors include onychogryphosis or distorted thickened nail, trauma to the nail or nail fold, fungal infection (onychymosis), poorly fitting shoe and improper trimming of the lateral edges of the nail plate.
The pathology of ingrown toenail begins with the penetration of the nail plates to the nail fold which later causes an inflammation. The opening of the nail folds will cause the bacterial and fungal to enter and leads to bacterial and fungal infection which later resulted in the formation of abscess. The tissue that has been inflamed and infected will be hypertrophied and cover the nail plate.
The patient may complain of pain, swelling, redness and drainage in the region of the toenail. The physical examination may reveal tenderness at the lateral nail fold, redness ( erythema ) , edema , serous/purulent discharge, hypertrophic lateral nail fold and formation of granulation tissue.
The investigation required include lab test such as full blood count and blood culture to detect the presence of systemic infection if it is suspected. The imaging technique is performed if osteomyelitis is suspected. The imaging technique may includes X-ray, MRI scan and bone scan. X-ray is considered and performed if subungual exostosis is suspected.
The differential diagnosis of ingrown toenail may include onycholysis ( separation of nail from the nail bed ), felon ( formation of a deep abscess on the plantar of the toe ), cellulitis, oncychogryphosis ( hardening and thickening of the nail grossly ), osteomyelitis , fungal infection of the nail ( onychomycosis ) , subungual exostosis ( formation of the osteochodroma that is present beneath the nail ) and paronychia.
The treatment of ingrowing toenails depends on the stages of the ingrowing toenails. In stage 1 ingrowing toenail (inflammation of the lateral nail fold) is best treated by asking the patient to wear a properly fitted shoe, trimmed the nail properly and soaks the feet in warm water twice a day.
Other treatment for stage 1 of ingrown toenail may include taping, dental floss and cotton wool as well as cryotherapy.
Taping may include the use of surgical tape. The surgical tape is applied on both sides of the toe. Then, another piece of the tape is used from one side of the toe to another side of the toe. The aim of this procedure/ action is to pull the lateral nail fold away from the nail plate. The patient is instructed to keep taping and stop after the nail has grown beyond the lateral nail fold.
Dental floss is another treatment option of ingrowing toenails. Dental floss is inserted bluntly to lift the nail away from the lateral sides of the nail fold. The patient is reminded to change and replace the floss frequently as it may get dirty and infected. Flossing is performed until the nail has grown beyond the lateral nail fold.
Another option may include the usages of cotton wool. The wisp cotton wool is inserted under the ingrown toenail. The patient is instructed to reinsert the cotton wool if the cotton wool comes out until the nail has grown beyond the nail fold. Silver nitrate cautery of the lateral nail fold is considered as an addition which is performed at home.
Cryotherapy is performed as an alternative at the lateral nail fold.
Cotton wool therapy and cryotherapy are performed for stage 2 of an ingrowing toenail (formation of the abscess).
Other treatment may include total or partial simple nail avulsion. Total or partial simple nail avulsion with phenol appears to be more effective than surgical excision of the nail bed at preventing the recurrence of the symptoms ingrowing toenail. In stage 2 and stage 3 , the effective treatment may include a flexible gutter splint. Surgical treatment with an additional of oral and topical antibiotics is not helpful in treating the ingrown toenail.
The drugs that are used may include NSAIDS which provide adequate analgesic. The use of topical corticosteroid is rarely performed on the lateral nail fold that is hypertrophic.
The surgical procedures are performed for stage 2 of ingrown toenail which fail to respond to conservative treatment or for stage 3 ingrowing toenail and recurrent episodes of ingrowing toenails. These may include partial avulsion of the nail with phenol ablation of the nail matrix. This procedure may include application of local anaesthesia, follow by placement of a tourniquet with a longitudinal incision of the nail a few mm from the border of the ingrown toenail begin from the distal edges that proceed to the matrix. It is performed with a nail splitter and scissors. Hemostat or (Freer) periosteal elevator is used to elevate the ingrown toenail from the nail bed. Hemostat is then used to gently pull this portion of the ingrown toenail. The urethral swab that is dipped with 88% of phenol solution is applied for 30 seconds to the nail matrix. Phenol application is applied more than one.
Another surgical procedure may include application of the flexible gutter splint. An IV tubing which is 2- 3 mm in diameter or cap of the 29 gauge needle (sterilized plastic tube) is cut 1- 2 cm long. Then a slit is made in the tubing and the end of the tube is cut off an angle. Next, local anaesthesia is applied. A hemostat is used to release the ingrown toenail that forms the nail fold. The tube is slide with the angle end first along the edges of the ingrown toenail. The tube is fixed in place with acrylic resin that is used for sculptured nail and denture. The tube us left in place until the nail has grown beyond the nail folds.
Other options may include ablation of the nail matrix that is performed by surgical excision, curettage and electrocautery. Electrocautery is performed with Teflon coated on a special flattened tip on one side.
Distal wing block and distal ring block are two forms of local anaesthesia performed. The distal wing block may include the infusion and the usage of 1 % of lidocaine near the junction of the lateral and proximal nail fold which is done with or without epinephrine. 1% of lidocaine infusion is continued until the tip of the digits of the distal part of the nail and nail folds are white as a result from the anaesthetic pressure effect.
The aim of digital ring block is to anaesthetize the dorsal digital nerves and plantar nerves. It is performed by infusion of 1% of lidocaine solution with or without epinephrine on the junction of the lateral and medial surfaces of the involved digits.
The follow up treatment may include dressing with potassium jelly or antibiotic ointment and later cover with tube gauge or sterile gauge.
Post operatively, the patient is instructed to rest and for 12- 24 hours they are advised to elevate the foot. NSAIDS is an analgesic taken if the patient suffered from pain and discomfort. Dressing need to be change and daily wash with water and soaps. For 2- 6 weeks, expect a sterile environment / exudates. It takes around 6 - 12 months for Avulsed nails grow in case of no matrix ablation are performed. The patient is referred in case of swelling, redness and pain that is worse. A patient that undergoes conservative treatment may require every 7 - 10 days follow up in the office until improvement is noted.
The complication of ingrown toenail may include, damaged to the nail bed, deformity of the nail plates as a result of nail matrix that is damaged, rare cases of distal toe ischemia as a result of prolonged usage of tourniquet during surgery, aggressive ablation of the matrix that leads to damage to the periosteum or fascia, cellulitis after surgery, osteomyelitis, wound drainage postoperatively and permanent narrowing of the nail in case of matrix ablation performance.
Recurrence of ingrown toenail is highly likely if evaluation procedure is the only treatment performed (40% - 80%). 3% - 14%`chances of recurrence are detected if matrix ablation is performed with 6 % - 13% chances if gutter splint is used.
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