Medical Care
Once nails have started to grow in, the basement membranes of the cuticle are open to bacterial invasion, and action is needed to forestall progression. [19]
The edge of the nail should be elevated from the bed. This elevation can be accomplished by simply rolling a cotton wisp from the lateral side of the nail gently under the edge of the nail (in the case of a lateral ingrowth). Forcing the cotton wisp in from the tip is much more painful. If the nail is too ingrown to do this without pain, try soaking the foot in warm water. Soaking may soften the nail enough to allow elevation of the edge without much pain.
If soaking fails, perform a digital block before elevating the nail edge. The toe is exquisitely sensitive. The block may hurt more than the procedure if it is not performed slowly with a small (30-gauge) needle and buffered lidocaine.
Partial nail removal with cauterization of the nail matrix is curative in 70-90% of cases. [20] Alternatively, part of the nail plate may be removed by laser. [21] However, there is little to no advantage to the use of the laser over chemical cautery.
Chemical Cautery
Chemical cautery of the nail matrix can be done by using phenol or 10% sodium hydroxide. [22, 7, 23, 24] Obtain informed consent; consent should be obtained by the physician and not delegated. Make no guarantees of cure or lack of complications; explain the risk of infection, regrowth, and reoccurrence; and discuss the proposed procedure.
Prepare and drape the toe by using povidone-iodophor or a skin cleanser of choice, and perform a digital block at the metatarsal head or proximal phalanx. Use buffered lidocaine (usually without epinephrine, although there is no evidence to support this recommendation), and inject 1 mL at each digital nerve.
Using a nail cutter, elevate the ingrown portion of the nail, rolling the nail from the ingrown side toward the midline of the toe (shown in the photo below). Be sure to expose the germinal end of the nail (this end has a soft, feathered edge). The proximal end is under the cuticle and usually is white. Cut about one-fourth to one-third of the nail, perpendicular to the end of the nail. Discard the piece after showing it the patient.
Place a cotton-tipped applicator, soaked in super-saturated phenol or 10% sodium hydroxide, into the proximal sulcus exposed by removal of the germinal portion of the nail (shown in the photo below). Wait 60 seconds; repeat this step. Rinse the site, especially the sulcus, with rubbing alcohol. Use an alcohol-saturated applicator to ensure removal of all chemical.
The toe after the completed procedure is shown in the photo below.
Apply a light gauze dressing, and instruct the patient to change the gauze the next day and then daily for 3-5 days. The patient should expect a slight discharge as the body cleanses the nail bed. Importantly, this discharge should occur as the site improves in appearance; discharge and increasing signs of inflammation may mean infection or an incomplete removal of the nail fragments. (Also see Ingrown Toenail Removal.)
Consultation is encouraged for those patients with risk factors (eg, those with diabetes or compromised circulation) related to either the disease or the procedure. [25]
Surgical Care
Surgical procedures for ingrown toenails are performed under local anesthesia, including digital block, metatarsal block, and transthecal anesthesia. Surgical options for ingrown toenail include the following [26, 27, 15, 28, 29, 17] :
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Spicule excision and partial matricectomy, which is the excision of the affected part of the nail with a partial mechanical matricectomy.
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Chemical partial matricectomy, which is generally performed using phenol and is associated with a higher success rate than mechanical matricectomy.
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Wedge resection of the toenail and nail fold, which consists of excision of the affected part of the nail plate, partial matricectomy, and wedge dissection of the nail bed and the hypertrophic nail fold.
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Excision of the affected nail and total matricectomy, which is a more radical approach, consisting of excision of the affected nail, nail bed, and total chemical or mechanical matricectomy.
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Soft tissue nail-fold excision technique does not touch the nail and consists of wide excision of the soft tissue.
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Other techniques include electrocautery, radiofrequency ablation, and carbon dioxide laser ablation, have become the newest form of ingrown toenail management.
Surgical approaches to treatment are usually reserved for stage 3 onychocryptosis (ranulation tissue formation and hypertrophy of the lateral wall besides the significant erythema, edema, and discharge) or for those for whom nonsurgical treatments have been unsuccessful. [26]
In a retrospective study, by Romero-Perez et al, of 520 patients who underwent ingrown toenail surgery, surgical matricectomy was associated with a lower recurrence rate (8.2%) than chemical matricectomy with phenol (CMP) (17.8%), more pain (5.7/10 vs. 3.6/10), higher risk of infection (15.3% vs. 2.9%), and lower cosmetic satisfaction (7.3/10 vs. 8.0/10). [27]
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Appearance of typical ingrown toenail.
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Cutting the nail.
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Cauterizing the matrix.
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Appearance of toenail at end of the cauterizing procedure.
