Treatment of the Ingrown Toenail
Treatment of the Ingrown Toenail
The ingrown toenail (onychocryptosis) is a condition commonly encountered in primary care. The principal problem usually involves the erosion or puncture of skin on the lateral border of the great toe. The disorder can be stratified into three stages of severity. Stage I is defined as erythema, swelling and tenderness along the lateral nail edge. Increasing tenderness, and a bulging of the lateral nail fold over the nail plate is characteristic of Stage II. This stage also usually involves infection and abscess, and can be quite painful. As granulation and subsequently epithelial tissue covers the nail fold and of the lateral nail plate in Stage III, drainage of the abscess is restricted. Stage III will often become a chronic condition in which the presence of pain, erythema, and infection waxes and wanes every few weeks.
Ingrown toenails are rarely described in cultures where shoes are not worn, and the relationship between shoes and this disorder are well established, as Joseph G. Richardson described in 1905:
The feet are subject to many diseases, but the most common ones … ingrowing nails … are due to neglect of a few simple rules which nearly all adults know. Fashion decrees that certain shapes must be worn and the poor foot, willing to toil and bear, is pressed and pulled out of shape by misshaped shoes. [1]
Prevention if the problem should be the physician’s first course of action. The modern version of Dr. Richardson’s “few simple rules” is summarized in table 1.
Treatment
Several strategies are successfully employed for treatment of ingrown toenails without surgical intervention. The rationale for all of these methods is to separate the nail from the lateral nail groove, allowing injured tissue to heal, while encouraging the nail to grow normally.
The most common procedure, often attempted by patients before presenting to the physician, involves the placement of a cotton pledget into the lateral nailbed, and (if possible) under the offending nail edge. Combined with good nail care, proper trimming, and minimized pressure from shoes, this method is often effective for stage I and Stage II nails.
For advanced stage II and Stage III, the flexible tube procedure [2], performed under local anesthesia, involves advancing a 2mm lengthwise-incised flexible plastic tube over the lateral nail edge. The tube is fastened with wound closure strips (eg Steri-Strip™ 3M corp, dkfkdj), and the toe is then washed daily with a cleaning solution until the nail plate grows out normally, and erythema subsides.
An alternative to plastic tubing is a procedure described by Lazar [3] in which the toe is soaked and cleaned, then treated with EMLA cream. When adequate anesthesia is achieved, the nail fold is cleaned thoroughly, debrided, and the granulation tissue is cauterized with silver nitrate. A wound closure strip is then introduced diagonally under distal corner of the nail, advanced proximally, and left in place. (See figure X) The following day, the toe is soaked once again, and a new wound closure strip carefully inserted. The patient then repeats this process daily until the toe is healed (average 5 weeks).
Unique solutions without sufficient clinical evidence of success include cryotherapy of the granulation tissue along lateral nail border, and a metal spring that is glued to the nail plate, which pulls the nail edge upward. [4]
Surgical Intervention
Most authorities agree that Stage III requires surgical intervention. There is much disagreement, however, regarding the appropriate procedure. Many methods and techniques have been described in the literature. Techniques published in the 1920's are still being used.
Most of our experience involves some minor variations to the procedure described by Pfenninger [5]. After the risks (see table 2), alternatives, and benefits of the procedure are discussed with the patient, and consent is obtained, The patient is placed on the table supine with the ankles extended beyond the tabletop. The toe is painted with a betadine solution.
A digital block is performed using 5-10 ml of 1% xylocaine solution without epinepherine: A 25 or 27 guage needle either 1-1.5 inch is used. Pain associated with injection of xylocaine can be diminished with the use of buffered xylocaine, or EMLA cream applied to the injection site 2- 30 minutes prior to the procedure. A wheal is raised at the base of the toe on the dorsal surface and 1-2 ml of anesthetic is injected in the area of the extensor digital nerve. The needle is repositioned and advanced towards the plantar surface with 1-2 ml injected in the area of the plantar digital nerve. The procedure is repeated on the corresponding site on the opposite side of the toe. (see figure Z) We allow 5-15 minutes for the anesthesia to reach full effect, often seeing a quick "urgi" visit before returning to complete the procedure.
A rubber band, small Penrose drain, or the cut of a rubber glove digit may be placed at the base of the toe and used as a tourniquet. To use the cut end of a glove digit, first cut off the tip of the digit, and then cut the remaining piece off of the glove. Place this piece around the toe as far proximally as possible, and roll the distal cut end of the rubber proximally. This device can be twisted and looped over the end of the toe once or twice to obtain the appropriate balance of fit and comfort. In our experience the procedure also works well without the tourniquet. Keep in mind however, that if a phenol nail matrix ablation is planned it must be done in a bloodless field, as any blood will dilute the phenol resulting in a higher rate of nail growth recurrence.
The nail is loosened from the bed by using the flat pointed end of a scissors or “anvil style” nail splitters designed for this procedure (e.g. catalog #243 – Universal Foot Care, Northbrook, IL). The instrument should be pointed at a slightly upward angle just under the nail surface to avoid lacerating the nail bed. This is a complication of the procedure and may require closure with suture if severe. The instrument is introduced at the hyponychium and pushed back to the nail fold. For a partial removal loosen the lateral 25% of the nail. A scissors works well for nail loosening in younger patients. Patients with thicker, or damaged nails may require a thin periosteal elevator to help avoid laceration of the nail bed. The scissor or nail splitter is then used to cut the nail along the margin that has been loosened from the distal tip back to the nail fold. The nail piece to be removed is grasped medially with a hemostat or needle driver, and the nail is removed with an upward twisting motion in the direction of the affected side. After the nail is removed, granulation tissue should be excised by silver nitrate cautery, trimming with a scissors, or scalpel.
The exposed nail matrix may be ablated by various methods. We use Phenol ablation, but techniques using laser, radiofrequency, and surgical excision have been described. An 88% Phenol solution is placed on a cotton swab. The bottle of phenol should be kept in a dark place, with exposure to light minimized, as light will significantly diminish the effectiveness of the phenol. Old or light-exposed phenol will be yellow or brown, and fresh phenol will be clear and colorless. Replace the bottle every one to two months.
The swab should be soaked but not dripping, and placed in contact with the nail matrix under the proximal nail fold. We have found that fine tipped, calcium alginate (Ultrafine Calgiswab, Inolex Corp.) or dacron swabs (Spectrum Laboratories, Inc., Los Angeles, CA) on the end of a fine, flexible metal wire are optimal. The swab should remain in contact with the nail matrix for 1-2 minutes. The surrounding normal tissue may be coated with petroleum jelly prior to the application of phenol as a protective measure. Simple nail avulsion combined with phenol ablation is more effective at preventing symptomatic recurrence than avulsion without phenol. [6] Patient satisfaction is greater with the phenol procedure despite a small increase in the number of postoperative infections. We have had success with both procedures. When not performing a phenol ablation we have the patient put a small amount of cotton or a small piece of waxed dental floss under the leading edge of the nail as it grows out to prevent recurrence. This material can be left in place until it falls out, and then simply replaced.
Total nail removal is probably only necessary when the granulation tissue blocks drainage on both sides of the nail. If this is the case the nail may be totally loosened, cut in half and removed in two pieces by the procedure above. An alternative procedure for total nail removal is described by Birrer et al.: [7] an elevator is used to free the proximal nail fold and once it is completely free the elevator is used as a lever to pry the proximal portion of the nail away - revealing the matrix.
Aftercare
Most importantly, do not forget to remove the tourniquet, as this can cause necrosis and loss of the toe! The patient can’t feel the toe, and may not be able to distinguish postoperative pain from ischemia in the hours following surgery – especially if the toe is covered with a dressing. Subsequent postoperative care involves applying a non-adherent dressing to the nail bed with a gentle compression dressing over the top. The foot should be elevated as much as possible for 24 hours. The dressing can then be removed and warm water soaks started. Pain control is usually adequately achieved with Ibuprophen or Acetaminophen. It may be necessary to limit weight bearing and wearing shoes for 2-3 days after the procedure. Shoes with an adequate toe box to allow the toes to assume a natural position should be worn. The nail typically grows back in 3-6 months.
Reimbursement
Many payers will refuse payment if a bill is submitted for payment of CPT 11730 (Removal of nail plate) in the absence of an ICD-9 code and appropriate documentation in the chart that the ingrown nail is painful or infected. The procedure may otherwise be considered cosmetic. ICD-9 729.5 (foot pain) will serve this purpose.
Tables
Table 1
Caption: Prevention of ingrown toenails
Wear shoes that fit properly. Tight shoes can press on the toenails, causing them to become ingrown.
Trim nails squarely across the top. Nails that are trimmed into the corners are more likely to become ingrown.
Nails should not be cut shorter at the edges.
Keep your feet clean and dry.
Wear clean socks
Table 2
Caption:
Risks of partial nail avulsion with or without phenol matrixectomy
· Assess general risk to each patient in the context of their medical condition: age, associated illness, allergies, anticoagulant/aspirin therapy and anxiety
· As with any surgical procedure, there is risk of bleeding or infection.
· Even if matrixectomy is not to be attempted, damage to the nail matrix may occur – resulting in potential changes to the appearance of the nail.
· If phenol matrixectomy is to be performed, there is a slightly increased risk of infection, and injury to the surrounding tissue due to the caustic effect of phenol on healthy tissue.
Figure x
Figure Z .
. (we’ll need to work on this . . it’s supposed to be a digital block)
References
1. Richardson, JG, Ford, WH, Vanderbeck, CC. Medicology. New York: University Medical Society; 1905:1084-1085.
2. Lazar L, Erez I, Katz S. A conservative treatment for ingrown toenails in children. Pediatr Surg Int. 1999;15:121-2.
3. Schulte KW, Neumann NJ, Ruzicka T. Surgical pearl: nail splinting by flexible tube--a new noninvasive treatment for ingrown toenails. J Am Acad Dermatol. 1998;39:629-30.
4. Http://www.nailease.com. Haelan Medical Corp., P.O. Box 907 , Midvale, Utah 84047, USA.
5. Pfenninger JL, Fowler GC. Procedures for primary care physicians. . Mosby-Year Book primary care series. St. Louis: Mosby; 1994.XXX-XXX
6. Rounding C, Hulm S. Surgical treatments for ingrowing toenails. Cochrane Database Syst Rev. 2000;2.
7. Birrer RB, DellaCorte MP, Grisafi PJ. Common foot problems in primary care. . 2nd ed. Philadelphia: Hanley & Belfus; 1998:XXX-XXXX
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Online Resources:
Patient Information:
· FamilyDoctor.org
http://familydoctor.org/handouts/208.html
· ThriveOnline
http://www.thriveonline.com/health/Library/sports/sport67.html
Provider References:
· Emedicine
http://emedicine.com/cgi-bin/foxweb.exe/showsection@d:/em/ga?book=emerg&;topicid=593
· Podiatry Channel
http://www.podiatrychannel.com/ingrowntoenails/
· American College of Foot and Ankle Surgeons preferred practice guideline
http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00852
· Primary Care Online (free access – registration required)
http://www.primarycareonline.co.uk/clinical/minorsurgery/ingrowing.htm#ref1
Learning Objectives
The reader will understand methods of prevention of Ingrown toenails.
The Reader will be able to describe the stages of severity of ingrown toenails, and describe conservative treatment options for each.
The reader will understand the proper technique for performing partial nail avulsion with phenol matrixectomy.
QUESTIONS
1) Ingrown toenails can be prevented with:
a. “Buddy taping” the great toe to the 2nd digit prior to sporting activities.
b. Wearing snug shoes.
c. Cutting the nail corners square and long.
d. Cutting the nail short, with special attention to trimming deep into lateral and medial corners
e. Keep feet moist and soft – apply skin softener if necessary to great toe.
2) Stage II ingrown toenails:
a. Absolutely require surgical intervention to prevent long-term complications.
b. Always involve both medial and lateral nail edges of the affected toe.
c. Are often very painful, but can be managed conservatively with wound-closure strips, small plastic tubing, or cotton pledgets.
d. Never require antibiotic treatment.
e. Will resolve spontaneously in 2-3 weeks.
3) Partial nail avulsion with phenol matrixectomy:
a. Is performed under local anesthesia using EMLA or TAC.
b. Requires that a tourniquet always be used, or uncontrolled bleeding is likely to occur.
c. Is performed with 1% or 2% xylocaine with epinephrine.
