Ingrown toenail nail bed: Ingrown Toenail – OrthoInfo – AAOS
Ingrown Toenail – OrthoInfo – AAOS
If you trim your toenails too short, particularly on the sides of your big toes, you may set the stage for an ingrown toenail. Like many people, when you trim your toenails, you may taper the corners so that the nail curves with the shape of your toe. But this technique may encourage your toenail to grow into the skin of your toe. The sides of the nail curl down and dig into your skin. An ingrown toenail may also happen if you wear shoes that are too tight or too short.
An ingrown toenail.
When you first have an ingrown toenail, it may be hard, swollen and tender. Later, it may get red and infected, and feel very sore. Ingrown toenails are a common, painful condition—particularly among teenagers. Any of your toenails can become ingrown, but the problem more often affects the big toe. An ingrown nail occurs when the skin on one or both sides of a nail grows over the edges of the nail, or when the nail itself grows into the skin. Redness, pain and swelling at the corner of the nail may result and infection may soon follow. Sometimes a small amount of pus can be seen draining from the area.
Ingrown nails may develop for many reasons. Some cases are congenital—the nail is just too large for the toe. Trauma, such as stubbing the toe or having the toe stepped on, may also cause an ingrown nail. However, the most common cause is tight shoe wear or improper grooming and trimming of the nail.
The anatomy of a toenail.
Ingrown toenails should be treated as soon as they are recognized. If they are recognized early (before infection sets in), home care may prevent the need for further treatment:
- Soak the foot in warm water 3-4 times daily.
- Keep the foot dry during the rest of the day.
- Wear comfortable shoes with adequate room for the toes. Consider wearing sandals until the condition clears up.
- You may take ibuprofen or acetaminophen for pain relief.
- If there is no improvement in 2-3 days, or if the condition worsens, call your doctor.
You may need to gently lift the edge of the ingrown toenail from its embedded position and insert some cotton or waxed dental floss between the nail and your skin. Change this packing every day.
If excessive inflammation, swelling, pain and discharge are present, the toenail is probably infected and should be treated by a physician (see left image below). You may need to take oral antibiotics and the nail may need to be partially or completely removed (see middle image below). The doctor can surgically remove a portion of the nail, a portion of the underlying nail bed, some of the adjacent soft tissues and even a part of the growth center (see right image below).
Possible treatment options for an ingrown toenail.
Surgery is effective in eliminating the nail edge from growing inward and cutting into the fleshy folds as the toenail grows forward. Permanent removal of the nail may be advised for children with chronic, recurrent infected ingrown toenails.
If you are in a lot of pain and/or the infection keeps coming back, your doctor may remove part of your ingrown toenail (partial nail avulsion). Your toe is injected with an anesthetic and your doctor uses scissors to cut away the ingrown part of the toenail, taking care not to disturb the nail bed. An exposed nail bed may be very painful. Removing your whole ingrown toenail (complete nail plate avulsion) increases the likelihood your toenail will come back deformed. It may take 3-4 months for your nail to regrow.
Unless the problem is congenital, the best way to prevent ingrown toenails is to protect the feet from trauma and to wear shoes and hosiery (socks) with adequate room for the toes. Nails should be cut straight across with a clean, sharp nail trimmer without tapering or rounding the corners. Trim the nails no shorter than the edge of the toe. Keep the feet clean and dry at all times.
Proper and improper toenail trimming.
Ingrown Toenail Removal | AAFP
THOMAS J. ZUBER, M.D.
Ingrown toenail is a common problem resulting from various etiologies including improperly trimmed nails, hyperhidrosis, and poorly fitting shoes. Patients commonly present with pain in the affected nail but with progression, drainage, infection, and difficulty walking occur. Excision of the lateral nail plate combined with lateral matricectomy is thought to provide the best chance for eradication. The lateral aspect of the nail plate is removed with preservation of the remaining healthy nail plate. Electrocautery ablation is then used to destroy the exposed nail-forming matrix, creating a new lateral nail fold. Complications of the procedure include regrowth of a nail spicule secondary to incomplete matricectomy and postoperative nail bed infection. When performed correctly, the procedure produces the greatest success in the treatment of ingrown nails. Basic soft tissue surgery and electrosurgery experience are prerequisites for learning the technique.
Ingrown toenail, or onychocryptosis, is a commonly encountered problem in family practice. Patients usually present with pain in the affected nail but with progression, drainage, infection, and difficulty walking occur. Most patients present with ingrown toenail during the second and third decades of life, but teenagers often develop ingrown toenails after tearing the corners of their toenails.
Possible causes of ingrown toenails include improperly trimmed nails, hyperhidrosis, poorly fitting footwear, trauma, subungual neoplasms, obesity, or excessive external pressure. These alterations cause the nail to improperly fit into the lateral nail groove, producing edema and inflammation of the lateral nail fold.
Stage 1 ingrown toenails are characterized by erythema, slight edema, and pain with pressure to the lateral nail fold. Stage 2 is marked by increased symptoms, drainage, and infection. Stage 3 ingrown toenails display magnified symptoms, granulation tissue, and lateral nail-fold hypertrophy.
Many physicians advocate conservative management for stage 1 ingrown toenails, including warm soaks, cotton-wick elevation of the affected nail corner, or antibiotic therapy in the presence of infection (Table 1). Simple, partial nail avulsion has been tried for stage 2 nails but is successful in eradicating the condition in only 30 percent of patients. Stage 3 ingrown toenails can develop from a laterally pointing spicule of nail beneath the nail fold. Excision of the lateral nail plate combined with lateral matricectomy is believed to provide the best chance for eradication. In the treatment of stage 3 toenails, the associated granulation tissue and lateral wall hypertrophy also should be removed.
|Warm water soaks|
|Cotton-wick insertion in the lateral groove corner|
|Debridement (debulking) of the lateral nail groove|
|Silver nitrate cautery to the hypertrophied lateral nail tissue|
|Complete nail avulsion|
|Partial nail avulsion|
|Wedge resection of the distal nail edge|
|Partial nail avulsion with:|
|Sodium hydroxide matricectomy|
|Surgical excision of nail plate, nail bed, and matrix|
The surgical technique of lateral nail avulsion and matricectomy has achieved the greatest success in the treatment of ingrown nails. Lateral nail excision limits the amount of nail removed, leaving less of an area of exposed and tender nail bed. If a laterally pointing spicule of nail is found beneath the hypertrophied tissue of the lateral nail fold, it should be removed, and a new lateral nail edge should be created to allow the lateral nail fold to regrow normally. The technique of wedge excision often fails to remove the spicule. Nail removal without destroying the matrix of the nail that produces lateral nail growth can permit the lateral nail to regrow beneath the lateral nail fold, producing anotheringrown nail.
Historically, phenol has been used for matricectomy, but it produces irregular tissue destruction and can result in significant inflammation and discharge after the procedure. Laser works well for matricectomy but is too expensive for most offices. Electrosurgical matricectomy has demonstrated consistent results and is an easily learned technique for most family physicians.
Methods and Materials
The patient is placed in the supine position with knees flexed (foot flat on the table) or leg extended (foot hanging off the end of the table).
Nonsterile Tray for the Procedure
Place the following items on a nonsterile drape covering the Mayo stand:
10-mL syringe filled with 1 percent lidocaine (Xylo-caine), and a 30-gauge needle
4 × 4-inch gauze soaked with povidone-iodine solution
1 to 2 inches of 4 × 4 gauze
2 straight hemostats
Sterile rubber band (if desired)
Nail splitter (if desired)
Monsel’s solution and cotton-tipped swabs (if desired)
Electrosurgical unit (such as the Ellman Surgitron)
2-mm and 4-mm matricectomy electrodes (flat, Teflon-coated on one side)
5-mm ball electrode
Smoke evacuator with viral particle filtering system
Tray for Postprocedure Dressing
The patient is placed in the supine position, with the knees flexed (foot flat on the table) or extended (foot hanging off the end of the table). The physician wears nonsterile gloves.
The toe is prepped with povidone-iodine solution. A standard digital block is performed with 1 percent lidocaine (without epinephrine), using a 10-mL syringe and a 30-gauge needle. About 2 to 3 mL of lidocaine on each side of the toe is usually sufficient for adequate anesthesia. A wait of five to 10 minutes allows the block to become effective.
Some physicians use a sterile rubber band around the base of the toe for a dry operative field. A clean, unused rubber band can be placed in a sterilization pouch and put through an autoclave. Alternatively, pressure to the sides of the toes during the procedure can reduce bleeding. A tourniquet should be used for the shortest possible time only.
The toe is rewashed with surgical solution, and a fenestrated drape is placed over the foot, with the involved toe protruding through the drape. A nail elevator or the closed tips of iris scissors are slid under the cuticle to separate the nail plate from the overlying proximal nail fold.
The lateral one fourth or one fifth of the nail plate is identified as the site for the partial lateral nail removal. This area is usually where the nail curves down into the toe. The physician uses a nail splitter or bandage scissors, cutting from the distal (free) end of the nail straight back (proximally) beneath the proximal nail fold (Figures 1 and 2). A straight, smooth, new lateral edge to the nail plate is created. When the scissors cut through the most proximal edge of the nail beneath the cuticle, a “give” can be felt. FIGURE 1.
Normal nail anatomy. The nail plate (A) receives nutrition from the underlying nail bed (B). The nail plate is created by the nail matrix (C). The nail plate is visible from the proximal nail fold (cuticle) (D) to the distal or free edge (E). The lateral nail fold lies outside of the lateral nail groove (F) and is the area where ingrown nails develop. The nail matrix can be seen at the junction with the nail bed, called the lunula (G). The nail matrix extends to the lateral horns (H). The nail bed extends distally to the hyponychium (I).
ILLUSTRATIONS BY CHARLES H. BOYTERFIGURE 2.
Lateral nail avulsion. (A) An ingrown nail is seen with lateral nail fold hypertrophy on the left side of the nail. After administering digital or local anesthesia, scissors, a scalpel blade, or a nail splitter can be used to cut proximally and create a smooth, straight edge. Some physicians prefer to slide a flat nail elevator beneath the nail before making this cut in an effort to reduce trauma to the nail bed. (B) The free lateral nail now is grasped with a hemostat or clamp and removed. (C) The lateral nail bed and matrix are now exposed for ablation.
The physician grasps the lateral piece of nail with a hemostat, getting as much nail plate as possible into the teeth of the instrument. The lateral nail plate is removed, in one piece if possible, by rotating the fragment outward toward the lateral nail fold, while pulling straight out toward the end of the toe.
If the lateral nail plate breaks, the remaining nail is regrasped and pulled out. No fragment of nail plate should remain under the proximal nail fold.
Electrocautery ablation is used to destroy the nail-forming matrix beneath the area where the nail plate has been removed. The flat matricectomy electrode is coated on one side to avoid damage to the overlying proximal nail fold. The electrode is placed beneath the nail fold, just above the nail bed, and cautery is applied to a bloodless field using 20 to 40 W of coagulation current (setting, 2 to 4), with sparking, for two to 10 seconds, treating the entire exposed nail bed and matrix twice. A properly treated nail bed has a white appearance after electrocautery.
If excessive lateral granulation tissue is noted, the physician may consider removal with electrocautery ablation. A 5-mm ball electrode is moved back and forth over the lateral granulation tissue, coagulating with 40 to 50 W of current (setting, 4 to 5). The destroyed tissue can usually be wiped away with gauze, and the process repeated until a concavity reveals normal tissue at the base. This site will fill in as healing takes place over the next few weeks.
Antibiotic ointment is applied, a bulky gauze dressing is placed, and the patient’s foot is put in a disposable surgical slipper. The patient should apply antibiotic ointment daily until healing is complete. The patient should be given the instruction sheet and told to take ibuprofen (Motrin) and acetaminophen (Tylenol) for postoperative pain. Daily cleansing with warm water is encouraged, and strenuous exercise is discouraged for at least one week.
A pathology evaluation performed on tissue removed during ingrown toenail surgery is rarely needed; only when an abnormal growth or suspected malignancy is encountered would a specimen be sent for pathologic evaluation.
If increasing pain, swelling, redness, or drainage develop, the toe should be evaluated for infection. Infection is common after ingrown toenail removal. Early intervention with oral antibiotic therapy can be highly effective in preventing infectious complications.
Incomplete matricectomy can allow a spicule of new nail to grow laterally, interfering with the newly created lateral nail groove. A second procedure may be required to obliterate the lateral spicule if inadequate matricectomy is performed during the first procedure.
Prolonged Application of the Tourniquet Can Lead to Distal Toe Ischemia. Patients with distal toe ischemia usually present with duskiness, poor healing, occasional ulceration, and even necrosis of the affected digit. Ingrown toenail removal can be performed without a tourniquet, but it is easier with a bloodless surgical field. If a tourniquet is used, it should be removed as soon as possible.
Overaggressive Electrocautery to the Nail Matrix Can Damage the Underlying Tissues. Prolonged or high-current cautery has the potential to damage the fascia or periosteum underlying the nail matrix. If the toe is healing poorly several weeks after the procedure, the physician may consider debridement, antibiotics, and possible radiographic evaluation.
The Patient Returns After Two Weeks With a Swollen, Red, Inflamed Toe. Infection is not unusual after the procedure, and oral antibiotics can be liberally administered. Some physicians routinely prescribe antibiotics for a few days after the procedure. Management of aggressive infection can reduce the chance of patients developing the rare complication of osteomyelitis.
The Patient Complains That the Surgery Did Not Get Rid of the Ingrown Nail. If inadequate matricectomy is performed, a spike of nail can regrow along the new lateral nail fold. This laterally growing piece of nail creates another inflammatory reaction in the lateral toe, necessitating a second procedure. The physician must make sure that the lateral horn matrix cells under the proximal nail fold are adequately ablated the first time.
The Nail Bed Is Lacerated When the Nail Is Cut With the Bandage Scissors. The physician must cut with the smallest blade of the scissors beneath the nail. The tips of the scissors should be slightly angled upward to avoid lacerating the fragile nail bed beneath the nail plate. Usually, bleeding from superficial lacerations is controlled by electrocautery. Deep lacerations may require suture repair and removal of additional nail.
The Patient Is Surprised by the Postoperative Appearance of the Toe. Patients should be reminded that the procedure will permanently narrow the nail. In addition, the concavity left when the lateral granulation tissue is removed can be a shock, but patients can be reassured that the tissue will gradually fill in.
The technique of nail avulsion and matricectomy is easily learned by physicians with soft tissue surgery and electrosurgery experience. Physicians should have precepted patient procedures. Novice physicians may need 20 procedures before they are comfortable performing the procedure unsupervised. Experienced physicians may be comfortable after performing three to five procedures.
Ingrown nail – stages of the disease, methods of treatment
There will be no doubt that this is a serious and not at all trifling problem only for those who know firsthand what excruciating pain occurs if the case is neglected.
Approximately 10% of the country’s population suffers from an ailment – an ingrown nail, in other words, onychocryptosis. Typically, the toenail grows into the soft surrounding tissue.
How does a nail work?
A horn formation (plate) is called a nail. The nail is located in the nail bed. At the root of the nail is a matrix – due to it, the nail grows. If the matrix is damaged, then the nail will grow incorrectly or stop growing altogether. On the sides of the nail are skin folds, they are called the nail roller.
Causes of onychocryptosis
- genetic predisposition,
- wearing tight shoes,
- shoes with heels,
- incorrect pedicure,
- vascular disease of the lower extremities,
- fungal diseases,
- non-observance of personal hygiene,
Most often, an ingrown toenail occurs in young people. They try, during a pedicure, to round off the corners of the nail plate as much as possible, thereby disrupting the natural growth of the plate, it begins to grow into the soft tissue.
Stages of the disease
- The first stage is redness around the nail, swelling and slight discomfort when walking.
- The second stage – part of the nail cuts into the skin, swelling occurs. A person experiences obvious pain and not only when walking.
- The third stage – in addition to pain in the focus of inflammation, purulent discharge appears. The nail thickens. The so-called “wild meat” appears – tissue grows.
- Fourth stage – soft tissue granulation occurs. The disease becomes chronic. Difficult to treat.
If an ingrown toenail is not treated promptly, complications can occur. Inflammation can go to the bone (ostiomyelitis), up to gangrene and amputation of the toes.
At risk are people with diabetes, the elderly.
First of all, it is necessary to cut the nails correctly, the cut should be even (parallel to the nail roller), when carrying out a pedicure, it is necessary to hold the legs in a warm bath, and follow the rules of hygiene daily. Wear loose, comfortable shoes.
If the stage of the disease is first or second, then nail softeners are recommended. Orthopedic inserts, staples, springs, plates are also recommended. Devices are fixed on the nail in order to correct the deformation of the nail. The procedure is painless. Delivers a minimum of inconvenience. The use of cosmetic varnish is allowed. It is recommended to wear the devices for 3-4 months.
With fungal diseases, appropriate medications will help.
Gentle, painless method. As a rule, the nail plate is not completely removed. Remove only the ingrown part of the nail. Also, the infected tissue is cleared by the laser, preventing the process of further inflammation.
Radio wave treatment
No less popular method than all the others. When using it, the immune properties of the skin and tissues increase. No bleeding, no scarring.
The most radical. The ingrown edge of the nail, the nail bed and part of the nail root dry out. Either a wedge-shaped resection of the nail plate or a selective resection of the nail matrix is performed. In advanced cases, the nail is completely removed. The disadvantage of this procedure is that the nail plate is restored within six months.
Ingrown nail problems. Prevention and treatment in Novosibirsk
With the advent of spring, many fashionistas can’t wait to change their winter boots for frivolous sandals, because they really want to demonstrate well-groomed toenails in open shoes! What girl and woman will refuse attractive summer shoes with spicy stilettos Shoe designers, given the whims of modern fashionistas, probably do not suspect that their elegant creations can cause unbearable suffering from an ingrown toenail. How to avoid it and what to do if you are faced with the problem of an ingrown nail, told Yuri Leonidovich Starkov , head of the department of outpatient surgery at the Central Scientific and Medical Center on Titov, surgeon of the highest category, candidate of medical sciences.
Model shoes do not cause unpleasant symptoms for all women – usually those who have a foot and first toe are not subject to bone deformity are lucky, but there are not very many such lucky women. Additional factors aggravate the situation: valgus deformity of the 1st finger, flat feet (transverse and longitudinal), overweight (including during pregnancy).
What to do, where is the exit? What should be done to prevent the development of an ingrown toenail? First of all, it is necessary to eliminate the root cause of the disease, namely:
The fact is that nail fungus destroys the connection between the inner edge of the nail plate and the nail bed. In this case, the nail plate corroded by the fungus is deformed and cuts into the periungual ridges.
Exit: Consultation and treatment with a dermatologist.
Unresolved bone pathology of the foot:
Foot deformity (congenital or acquired): flat feet, especially transverse, clubfoot, valgus deformity of the first toe, which contributes to improper distribution of weight on the toes when walking.
The main biomechanical cause of forefoot overload is excessive pronation, a constant companion of flat-valgus and “pseudo-sex” feet. This is a condition when the edge of the nail plate falls between the hammer (sole of the foot) and the anvil (shoes), constantly injuring the soft tissues of the nail phalanx, which leads to the development of an ingrown nail.
- use of thumb valgus correctors,
- wearing orthopedic shoes,
- application of orthopedic insoles.
Constant wearing of narrow, uncomfortable shoes with high heels, which leads to a shift in the center of gravity and overload of the forefoot foot section. 1 cm heel – 10% load on the forefoot.
8 cm heel – 80% of the load on the forefoot, which contributes to the formation of transverse flat feet, deformation of the toes, and, as a rule, the development of an ingrown toenail.
Exit: Do not abuse the constant wearing of dress shoes with high heels.
Technically incorrect and low-quality pedicure
Promotes the development of local inflammation, the growth of granulation tissue (“wild meat”), secondary bacterial colonization and ultimately leads to the appearance of infectious complications, up to osteomyelitis of the nail phalanx.
If the nail plate is overweight, there is no chance for proper growth, and when walking, it will certainly injure the periungual ridge, which is one of the reasons for the development of an ingrown nail.
Exit: to fight the cause, namely, excess weight, because it is dangerous for a number of concomitant diseases (diabetes, metabolic syndrome, arterial hypertension, etc.).
It is no secret that many chemicals used in some beauty salons (acetone, formaldehyde, xylene, etc.) when performing pedicures and nail extensions cause depletion of the nail plate and its detachment from the actual nail bed. This very often becomes a trigger for future complications. A detached and deformed nail plate rarely restores its structure in the future, and sometimes loses its connection with the nail bed forever, which significantly affects the beauty of the nails.
Exit: take care of yourself and do not abuse salon procedures where aggressive chemicals are used.
Household injury of fingers
As a result of trauma, onychoblasts (growth cells) migrate in different directions of the soft tissues of the nail phalanx, thereby provoking uncontrolled growth of the matrix (nail root) and the nail plate.
Exit: In case of injury, seek surgical care in a timely manner, without waiting for complications in the form of an ugly deformity from a newly growing nail plate.
There are many ways to treat an ingrown toenail:
The choice of a specific method is largely determined by the stage of the disease at which the pathological process is located. It is very important to understand that conservative treatments are effective only in the early stages of the disease. But if the ingrown nail is accompanied by pain and inflammation, especially in combination with suppuration, it is urgent to consult a surgeon.
CNMT has developed and implemented a method for treating ingrown toenails, which can significantly improve the quality of human life and forget about this disease forever.