eMedicine Specialties > Pediatrics: General Medicine > Dermatology

Ingrown Nails

Author: Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Coauthor(s): Ann G Egland, MD, Consulting Staff, Department of Operational and Emergency Medicine, Walter Reed Army Medical Center
Contributor Information and Disclosures

Updated: Jul 20, 2009

Introduction

Background

Ingrown toenails are a fairly frequent cause of discomfort. Although often thought to be synonymous, the terms ingrown nail and paronychia refer to different conditions. Both can cause significant discomfort. Ingrown toenails may cause pain with ambulation.

Right great toe paronychia in a 3-year-old child....

Right great toe paronychia in a 3-year-old child. Photo courtesy of Ann G. Egland, MD.

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Right great toe paronychia in a 3-year-old child....

Right great toe paronychia in a 3-year-old child. Photo courtesy of Ann G. Egland, MD.

Pathophysiology

Ingrown nails result from an alteration in the proper fit of the nail plate in the usual nail groove. Sharp spicules of the lateral nail margin develop and are gradually driven into the dermis of the nail groove. The nail acts as a foreign body. An inflammatory response occurs in the area of penetration, leading to erythema, edema, purulence, and development of granulation tissue. Development of ingrown nails is divided into the following 3 stages (although some have included more1 ): (1) erythema, edema, and focal tenderness; (2) crusting and expressible purulence at the nail fold and nail plate junction; and (3) chronic infection with protuberant granulation tissue extending over the nail plate. Ingrown nails generally occur as the result of poorly fitted footgear. However, this may be caused by prior trauma to or abnormal shape of the nail margin.1

Frequency

United States

Of all nail problems, this is the most common. Toenails are affected much more commonly than fingernails. The lateral margins of the great toe are most frequently affected.

International

In the United Kingdom, 10,000 cases per year have been reported.

Mortality/Morbidity

In general, mortality is not associated with ingrown nails. Morbidity is chiefly the result of infection of the tissues. If neglected, abscess formation (paronychia) may occur or spread and lead to osteomyelitis, systemic infection, sepsis, or amputation.

Race

No racial predilection is noted.

Sex

Ingrown nail has a reported male-to-female ratio of 3:1.

Age

The condition is observed in people of all ages but is most common in the second decade of life. Ingrown nails become much more common as children begin bearing weight on their feet and wearing shoes, although congenital onychocryptosis has been described,2,3 as have cases in infants.4

Clinical

History

Patients present for care of ingrown nails due to discomfort. Ingrown nails may cause significant pain. If a toenail is involved, the discomfort worsens with weightbearing and ambulation.

  • The patient with an ingrown nail presents with a sharp, focal pain adjacent to the nail bed of the affected digit.
  • The patient or parents may typically describe crusting, purulence, and friable granulation tissue at the site.

Physical

Upon examination, the following may be present:

  • Edema or inflammation of tissue surrounding the nail bed
  • Erythema of the same tissue
  • Macerated or friable granulation tissue
  • Crusting
  • Drainage
  • Hypertrophy of the nail margin
  • Hypertrophy of the surrounding epidermis

Causes

The nail plate can be forced out of the nail groove by footgear that has a toe box that is too small for the forefoot, by trauma, or by cutting the nail back in a curvilinear fashion.

  • Other causes include the following:
    • Heredity : Some people are genetically predisposed to inwardly curved nails with distortion of one or both nail margins.
    • Underlying bony pathology causing deformation of the nail
    • Obesity causing deepening of the nail groove
    • Antiviral therapy for HIV: Indinavir has also been reported to have an association with increased incidence of ingrown nails.5
    • Prior trauma resulting in an irregularly shaped nail

More on Ingrown Nails

Overview: Ingrown Nails
Differential Diagnoses & Workup: Ingrown Nails
Treatment & Medication: Ingrown Nails
Follow-up: Ingrown Nails
Multimedia: Ingrown Nails
References
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References

  1. Martinez-Nova A, Sanchez-Rodriguez R, Alonso-Pena D. A new onychocryptosis classification and treatment plan. J Am Podiatr Med Assoc. Sep-Oct 2007;97(5):389-93. [Medline].

  2. Grassbaugh JA, Mosca VS. Congenital ingrown toenail of the hallux. J Pediatr Orthop. Dec 2007;27(8):886-9. [Medline].

  3. Lee JH, Kim SE, Park K, Son SJ. Congenital ingrown toenails successfully treated with simple plastic tube insertion. Int J Dermatol. Feb 2008;47(2):209-10. [Medline].

  4. Sarifakioglu E, Yilmaz AE, Gorpelioglu C. Nail alterations in 250 infant patients: a clinical study. J Eur Acad Dermatol Venereol. Jun 2008;22(6):741-4. [Medline].

  5. Luther J, Glesby MJ. Dermatologic adverse effects of antiretroviral therapy: recognition and management. Am J Clin Dermatol. 2007;8(4):221-33. [Medline].

  6. Shaikh FM, Jafri M, Giri SK, Keane R. Efficacy of wedge resection with phenolization in the treatment of ingrowing toenails. J Am Podiatr Med Assoc. Mar-Apr 2008;98(2):118-22. [Medline].

  7. Rounding C, Bloomfield S. Surgical treatments for ingrowing toenails. Cochrane Database Syst Rev. Apr 18 2005;CD001541. [Medline].

  8. Bostanci S, Kocyigit P, Gurgey E. Comparison of phenol and sodium hydroxide chemical matricectomies for the treatment of ingrowing toenails. Dermatol Surg. Jun 2007;33(6):680-5. [Medline].

  9. Yang G, Yanchar NL, Lo AY, Jones SA. Treatment of ingrown toenails in the pediatric population. J Pediatr Surg. May 2008;43(5):931-5. [Medline].

  10. [Best Evidence] Bos AM, van Tilburg MW, van Sorge AA, Klinkenbijl JH. Randomized clinical trial of surgical technique and local antibiotics for ingrowing toenail. Br J Surg. Mar 2007;94(3):292-6. [Medline].

  11. Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician. Feb 15 2009;79(4):303-8. [Medline].

  12. Czarnowski C, Ponka D, Rughani R, Geoffrion P. Toenail resection: minor surgery video series. Can Fam Physician. Nov 2008;54(11):1555. [Medline].

  13. Chapeskie H. Ingrown toenail or overgrown toe skin?: Alternative treatment for onychocryptosis. Can Fam Physician. Nov 2008;54(11):1561-2. [Medline].

  14. Aksoy B, Aksoy HM, Civas E, Oc B, Atakan N. Lateral foldplasty with or without partial matricectomy for the management of ingrown toenails. Dermatol Surg. Mar 2009;35(3):462-8. [Medline].

  15. Orenstein A, Goldan O, Weissman O, et al. A comparison between CO2 laser surgery with and without lateral fold vaporization for ingrowing toenails. J Cosmet Laser Ther. Jun 2007;9(2):97-100. [Medline].

  16. Ishibashi M, Tabata N, Suetake T, et al. A simple method to treat an ingrowing toenail with a shape-memory alloy device. J Dermatolog Treat. 2008;19(5):291-2. [Medline].

  17. Moriue T, Yoneda K, Moriue J, et al. A simple therapeutic strategy with super elastic wire for ingrown toenails. Dermatol Surg. Dec 2008;34(12):1729-32. [Medline].

  18. [Guideline] Gahagan S, Silverstein J. Prevention and treatment of type 2 diabetes mellitus in children, with special emphasis on American Indian and Alaska Native children. American Academy of Pediatrics Committee on Native American Child Health. Pediatrics. Oct 2003;112(4):e328. [Medline].

  19. Edlich RF, Winters KL, Britt LD. Bacterial diseases of the skin. J Long Term Eff Med Implants. 2005;15(5):499-510. [Medline].

  20. Gross RH. Foot pain in children. Pediatr Clin North Am. Dec 1986;33(6):1395-409. [Medline].

  21. Ilfeld FW. Ingrown toenail treated with cotton collodion insert. Foot Ankle. Apr 1991;11(5):312-3. [Medline].

  22. Information from your family doctor. Ingrown toenails. Am Fam Physician. Feb 15 2009;79(4):311-2. [Medline].

  23. Manusov EG, Lillegard WA, Raspa RF. Evaluation of pediatric foot problems: Part I. The forefoot and the midfoot. Am Fam Physician. Aug 1996;54(2):592-606. [Medline].

  24. Noronha PA, Zubkov B. Nails and nail disorders in children and adults. Am Fam Physician. May 1 1997;55(6):2129-40. [Medline].

  25. Rich P. Nail disorders. Diagnosis and treatment of infectious, inflammatory, and neoplastic nail conditions. Med Clin North Am. Sep 1998;82(5):1171-83, vii. [Medline].

  26. Robbins JM. Recognizing, treating, and preventing common foot problems. Cleve Clin J Med. Jan 2000;67(1):45-7, 51-2, 55-6. [Medline].

  27. Rockwell PG. Acute and chronic paronychia. Am Fam Physician. Mar 15 2001;63(6):1113-6. [Medline].

  28. Zuber TJ. Ingrown toenail removal. Am Fam Physician. Jun 15 2002;65(12):2547-52, 2554. [Medline].

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Further Reading

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Keywords

ingrown nails, acronyx, ingrown fingernail, ingrown toenail, onychocryptosis, paronychia, unguis incarnatus, unguis aduncus, sepsis, osteomyelitis, obesity, diagnosis, treatment

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Contributor Information and Disclosures

Author

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Coauthor(s)

Ann G Egland, MD, Consulting Staff, Department of Operational and Emergency Medicine, Walter Reed Army Medical Center
Ann G Egland, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Association of Military Surgeons of the US, Medical Society of Virginia, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center
Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

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