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Ingrown Nails Treatment & Management

  • Author: Amira M Elbendary, MBBCh, MSc; Chief Editor: William D James, MD  more...
 
Updated: Jan 19, 2016
 

Medical Care

Conservative management is used in stage 1 ingrown nails, with the advantage of avoidance of minor surgical procedures with their associated pain and short-term disability.

General measures

Well-fitted shoes with a wide toe box or open toe are recommended.

Trim toenails properly, with avoidance of cutting back to the lateral margins in a curved pattern.

Manage underlying possible predisposing factors such as onychomycosis and hyperhidrosis.

Soak the affected toe in warm water, followed by application of topical antibiotics or silver nitrates in case there is granulation tissue.

Conservative methods

Cotton wick insertion in the lateral groove corner is one method. Using a nail elevator or small curette, small wisps of cotton are inserted under the lateral edge of the ingrown nail. Symptomatic improvement was reported in 79% of patients in a case series with mean follow up of 24 weeks.[16] See the image below.

Schematic view for cotton wick insertion. Courtesy Schematic view for cotton wick insertion. Courtesy of Dermatology Research and Practice (Haneke, E. "Controversies in the Treatment of Ingrown Nails." Dermatology Research and Practice. 2012; 2012:783924).

Toe taping is an alternative method. The affected toe is taped in a way that the one end of the tape is placed on the side of the ingrown nail along the granulation tissue and twisted around the toe at an angle, with the other end overlapping the first without covering the wound itself. This taping allows drainage of accumulated pus, drying of the wound, and decreasing the pressure on the nail bed.[17] See the image below.

Schematic view illustrating taping of the nail. Co Schematic view illustrating taping of the nail. Courtesy of Dermatology Research and Practice (Haneke, E. "Controversies in the Treatment of Ingrown Nails." Dermatology Research and Practice. 2012; 2012:783924).

Nail splinting by flexible tube (gutter treatment) involves a small sterilized vinyl intravenous drip infusion tube, which is cut and slit appropriately from top to bottom with one end cut diagonally for smooth insertion. The lateral edge of the affected nail plate is splinted with this tube under local anesthesia. The plastic tube is then covered by adhesive or wound closure strips and the patient is instructed to wash his or her toe daily with povidone iodine solution for 3-4 weeks. This method allows the nail spicule to grow without injuring the nail fold, and the inflammatory process will subside.[18] See the image below.

Schematic view illustrating gutter technique. Cour Schematic view illustrating gutter technique. Courtesy of Dermatology Research and Practice (Haneke, E. "Controversies in the Treatment of Ingrown Nails." Dermatology Research and Practice. 2012; 2012:783924).

The split tape-strap technique is a procedure that involves elastic tape cut into pieces about 3 cm wide and about 10 cm long, folded longitudinally in half. A slit is then created on the width of the ingrown nail along the short edge of one third of the tape length. The ingrown nail is then inserted in the slit, orienting the tape with the shorter side of the tape towards the dorsal side of the toe and hooking the slit edge of the longer side on the ingrown nail and attaching it to the plantar surface of the toe. This procedure showed favorable results as monotherapy or when combined with other conservative procedures.[19]

 Other methods reported to be effective but on a smaller number of patients include angle correction technique,[20] dental floss technique,[21] nail wiring,[22] nail brace,[23] knot technique,[24] Nishioka procedure,[25] and use of an artificial acrylic nail.[26]

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Surgical Care

Different surgical modalities have been described.[27]

Nonselective surgical management can include the following procedures:

  • Complete nail evulsion
  • Partial nail evulsion
  • Wedge matrix excision
  • Partial matrix excision
  • Total matrix excision
  • Vandenbos procedure [20]

These procedures were reported to have high recurrence rates.

Partial nail avulsion surgical techniques are as follows:

  • Phenol matricectomy: It is the most commonly used chemical agent for matricectomy, with good results and a low recurrence rate; however, because of the extensive tissue damage it causes, drainage and delayed wound healing may occur. [28] Dizziness, abdominal pain, hemoglobinuria, cyanosis, and cardiac arrhythmias are adverse effects that have been reported following phenol application. [29] Application of phenol for 1 minute duration has a better safety profile than prolonged application and is sufficient for destruction of the germinal matrix. [29]  Use of an antimicrobial hydrogel containing oakin, an oak extract, may help reduce phenol caustic activity and healing time. [30]
  • Chemical matricectomy with 10% sodium hydroxide: This is as effective as phenol. It acts through liquefactive necrosis by alkali burning, resulting in less postoperative drainage and a shorter healing time. However, care should be taken to not apply strong alkali for prolonged periods, as this may cause excessive tissue damage by from slowly progressive liquefactive necrosis. [31]  Additional adverse effects described following sodium hydroxide matricectomy include allodynia, nail dystrophy, and hyperalgesia. [32]
  • Trichloroacetic acid matricectomy: This method has high rates of success, a low recurrence rate, and low postoperative morbidity. [33]
  • Matricectomy using carbon dioxide laser: Performing selective matricectomy using a carbon dioxide laser is associated with a low recurrence rate, but technical difficulty, prolonged healing time, and poor cosmetic results are drawbacks for such a procedure. [34]
  • The Winograd procedure (wedge resection): This involves local anesthesia and digital tourniquet application followed by a longitudinal incision along the eponychium followed by removal of the lateral nail border, hypertrophied tissue, and germinal matrix. [35]
  • Wedge excision and phenol matricectomy
  • Cryotherapy
  • Electrocautery or curettage: Both methods are safe with high success rates. Curettage was found to be superior to electrocautery regarding postoperative inflammation and pain. Electrocauterization may cause heat osteonecrosis that may result in prolonged postoperative pain from the heat generated from the periosteum. [36]

The use of local anesthetics that contain vasoconstrictors has shown to be effective, eliminating the adverse effects of using a digital tourniquet (lower anesthetic effect and postoperative bleeding). Reduction of postoperative bleeding and perioperative pain can be achieved with the addition of epinephrine to the local anesthetic, but use caution so as not to inject it into an artery.[37]

Postoperative care

The patient is allowed to walk after the operation.

Rest at home with feet elevation is recommended, with intake of analgesics when needed.

Normal ambulation and activity can be resumed as soon as 48 hours after the operation.

The patient is instructed to use antiseptic soaks with diluted povidone-iodine solution once a day for 15 minutes, followed by topical antibiotic cream and gauze.

Always keep the wound dry and clean.

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Consultations

Consult a podiatrist, dermatologist, or orthopedic surgeon for routine follow-up care or for patients in whom primary avulsion therapy has been unsuccessful.

Close follow-up care with an orthopedist is required if inflammatory osteophytic changes are observed or if evidence of osteomyelitis is present. Immediate antibiotic treatment should begin, and inpatient treatment may be needed for osteomyelitis.

Follow-up with a primary care physician is indicated for any type of immunosuppression, including diabetes mellitus. Antibiotics may be started in those who are immunosuppressed.

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Diet

No dietary limitations are required.

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Activity

Rest, keep the extremity elevated, keep the site dry, and maintain limited weightbearing until healing has taken place.

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Contributor Information and Disclosures
Author

Amira M Elbendary, MBBCh, MSc Visiting Research Fellow, Ackerman Academy of Dermatopathology; Teaching Assistant, Department of Dermatology, Kasr Alainy University Hospital, Cairo University, Egypt

Amira M Elbendary, MBBCh, MSc is a member of the following medical societies: Medical Dermatology Society, Bloom’s Syndrome Association, Egyptian Medical Syndicate, International Dermoscopy Society

Disclosure: Nothing to disclose.

Coauthor(s)

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Kevin P Connelly, DO Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; 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, American Osteopathic Association

Disclosure: Nothing to disclose.

Acknowledgements

Thomas Craig, MD Resident Physician, Department of Emergency Medicine, Naval Medical Center

Disclosure: Nothing to disclose.

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.

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Right great toe paronychia in a 3-year-old child. Courtesy of Ann G. Egland, MD.
Preparing for digital block before surgical treatment of paronychia of right great toe. Universal precautions should always be observed. Courtesy of Ann G Egland, MD.
Neonatal ingrown nail. Courtesy of Dermatology Research and Practice (Haneke, E. "Controversies in the Treatment of Ingrown Nails." Dermatology Research and Practice. 2012; 2012:783924).
Pincer nail. Courtesy of Dermatology Research and Practice (Haneke, E. "Controversies in the Treatment of Ingrown Nails." Dermatology Research and Practice. 2012; 2012:783924).
Stage 3 ingrown nail. Courtesy of Wikimedia Commons.
Schematic view for cotton wick insertion. Courtesy of Dermatology Research and Practice (Haneke, E. "Controversies in the Treatment of Ingrown Nails." Dermatology Research and Practice. 2012; 2012:783924).
Schematic view illustrating taping of the nail. Courtesy of Dermatology Research and Practice (Haneke, E. "Controversies in the Treatment of Ingrown Nails." Dermatology Research and Practice. 2012; 2012:783924).
Schematic view illustrating gutter technique. Courtesy of Dermatology Research and Practice (Haneke, E. "Controversies in the Treatment of Ingrown Nails." Dermatology Research and Practice. 2012; 2012:783924).
Hypertrophy of the lateral nail fold that partially cover the nail. Courtesy of Dermatology Research and Practice (Haneke, E. "Controversies in the Treatment of Ingrown Nails." Dermatology Research and Practice. 2012; 2012:783924).
 
 
 
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