Ingrown Nails Treatment & Management

Updated: Apr 22, 2019
  • Author: Amira M Elbendary, MBBCh, MSc; Chief Editor: William D James, MD  more...
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Treatment

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. [24] 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. [25] 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. [26] 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. [27]

Other methods reported to be effective but on a smaller number of patients include angle correction technique, [28] dental floss technique, [29] nail wiring, [30] nail brace, [31] knot technique, [32] Nishioka procedure, [33] and use of an artificial acrylic nail. [34]

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Surgical Care

Different surgical modalities have been described. [35]

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 [28]

These procedures were reported to have high recurrence rates. However, a retrospective study from 2017 to evaluate the Vandenbos procedure reported on 59 ingrown toenails and found that while 18% of patients had one or more minor complications with in the first 2 months of surgery, no recurrences were reported. [36]

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. [37] Dizziness, abdominal pain, hemoglobinuria, cyanosis, and cardiac arrhythmias are adverse effects that have been reported following phenol application. [38] Application of phenol for 1 minute duration has a better safety profile than prolonged application and is sufficient for destruction of the germinal matrix. [38]  Use of an antimicrobial hydrogel containing oakin, an oak extract, may help reduce phenol caustic activity and healing time. [39]

  • 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. [40]  Additional adverse effects described following sodium hydroxide matricectomy include allodynia, nail dystrophy, and hyperalgesia. [41]

  • Trichloroacetic acid matricectomy: Chemical matricectomy using 90% trichloroacetic acid was tested following partial nail avulsion and was found to be helpful, with low rates of postoperative morbidity. [42] Trichloroacetic acid had shown high success rates with a healing time of less than two weeks. [43, 44]

  • 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. [45]

  • 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. [46]

  • 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. [47]

In a study aiming to compare the wedge resection method and chemical matricectomy using sodium hydroxide, postoperative pain severity, drainage rate, and recovery time were reduced with chemical matricectomy. [48] However, there was no difference regarding recurrence rate.

Trichloroacetic acid was found to be as effective as phenol. It remains an option when phenol is not available. [49]

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. [50]

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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Prevention

Good hygiene and wearing appropriately sized footgear are important. Shoes with narrow, pointed toes that compress the forefoot should not be worn.

Teaching the patient and parents to keep the nail margin in the nail groove, how to properly trim the nail, and how to choose shoes with an accommodating toe box is vital to prevent further visits.

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Long-Term Monitoring

Provide appropriate follow-up care as indicated. Provide patients and parents with specific indications for return, such as development of infection, bleeding, or any worsening of the condition of the digit.

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