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 Examination

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

Accordingly, ingrown nail has been divided into the following three stages^[20]:

Stage 1: Mild erythema edema and pain with pressure
Stage 2: Significant erythema, edema, local infection, and discharge
Stage 3: Granulation tissue formation and hypertrophy of the lateral wall besides the significant erythema, edema, and discharge (see image below)

Stage 3 ingrown nail. Courtesy of Wikimedia Commons.
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Complications

Development of paronychia is the most common complication. If paronychia is not treated, the condition may progress to cellulitis, osteomyelitis, or systemic infection.

If neglected, abscess formation (paronychia) can spread and lead to osteomyelitis, systemic infection, and sepsis; amputation of the digit may even be required for definitive treatment.

An ingrown nail causes varying degrees of inflammation in the surrounding tissue, and this may predispose to infection if not well treated.

Hypertrophy of the medial and lateral skin folds may occur, as shown in the image below, and bilateral sidewall hypertrophy that covers the entire nail has been reported.^[21]

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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Pyogenic granuloma may develop on longstanding infected ingrown nails.

If left untreated, chronic inflammation may cause skin bridging secondary to epithelialization of the adjacent inflamed hypertrophied soft tissue.^[22]

Keloid formation may result from chronic inflammation, especially in cases of recurrent ingrown nails.^[23]

Recurrence is defined as the occurrence of pain, discomfort, erythema, and/or drainage at the site of the treated nail edge.

Although infrequent, postsurgical infection may occur in a small percentage of patients. Appropriate precautions should be given to return for any signs of infection or fever.

Differential Diagnoses

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Media Gallery

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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Author

Amira M Elbendary, MD, MBBCh, MSc Visiting Dermatopathology Fellow, Ackerman Academy of Dermatopathology; Lecturer, Department of Dermatology, Kasr Alainy University Hospitals, Cairo University, Egypt

Amira M Elbendary, MD, MBBCh, MSc is a member of the following medical societies: Bloom’s Syndrome Association, Egyptian Medical Syndicate, International Dermoscopy Society, Medical Dermatology 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, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

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: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

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.