Ingrown Toenail

If your attempt at home surgery failed or you simply just want the ingrown problem taken care of by a professional, go and see a foot specialist.

Ingrown nails can occur in any toe but are most common in the hallux nail.  The medical term for this disorder is called onychocryptosis.  The most common causes are a genetic malformation of the nail margin and nail groove (the nail might be too wide for the toe), trauma to the nail or nail bed, improper trimming of the nail or ill-fitting shoes, or stockings.  There is a space between the nail margin and the nail groove, it is filled with a thin layer of epithelium (skin cells) that protects the groove from irritation.  However, if you have an abnormal shape to the nail or ill-fitting shoes creating pressure or trauma to the nail, this can obliterate the space between the nail plate margin and the nail groove.

 

This produces constant irritation to the nail borders.  The reactive swelling in the groove leads to an enlarged swollen nail border.  As this process continues the nail groove is finally incised by the nail margin, often with ensuing secondary infections. If the chronic condition continues without treatment, then granulation tissue can develop along the nail edge.  Granulation tissue is bright red tissue that bleeds freely with a slight provocation.  In the early stages of an ingrown nail, you may experience swelling and redness along the lateral nail fold.  The edge of the nail plate may be embedded in an irritated nail fold.  As the condition progresses you can experience an increase in pain, acute infection, and possible drainage.  If the condition is still not cared for you may end up with a chronic infection, granuloma, and the surrounding soft tissue is swollen and thick.

 

There are a few options for treating an ingrown nail.  I caution you on a few of the home remedies.  Soaking the toe in Epsom salts or OTC ingrown toenail soak often can help reduce the drainage, the edema, and ease the pain.  However, soaking will not remove the offending border, oftentimes the pain, swelling, drainage, and infection can re-occur.  You can attempt to trim the nail or cut the nail out of the corner; however, this could cause you to pierce or cut the skin leading to an infection.  The ingrown nail occurs along with the entire nail plate so removing the end of the nail that is piercing the skin will not remove the ingrown but more than likely only give you temporary relief.  As the nail grows back out the pain will often return.  I do not recommend lifting the nail edge with the

type of foreign material, this will not cause the nail to grow out straight again and only puts you at a high risk of infection, either bacterial or fungal.

If your attempt at home surgery failed or you simply just want the ingrown problem taken care of by a professional, go and see a foot specialist.  They will offer you two types of treatment for the ingrown toenail.  They may recommend an avulsion of the nail edge that is ingrown.  This is a temporary type of procedure.  It will allow the nail edge to grow back.  If the nail was ingrown due to trauma or ill-fitting shoes the new nail may grow back straight, not painful, and not ingrown.  Most of the time, however, I would say at least 8 times out of 10 your nail is going to grow back ingrown and the whole problem will start over again.   Sometimes the foot doctor will do an avulsion when there is a significant infection present or there has been a significant trauma.  In this case, the nail bed needs to heal before a more permanent procedure can be performed.

The next option they may recommend is a permanent procedure called a matrixectomy.  This is a procedure in which they destroy the cells the nails grow.  This can be done in a couple of different ways.  It can either be done with acid, lasers, or surgically cutting the cells out.  This option will get rid of the painful and potentially infectious causing nail edge permanently, so you no longer need to worry over the nail or perform any more at-home surgery.

 

What should you expect or do to prepare for an ingrown appointment or procedure?  Most physicians will perform the procedure whether it is an avulsion or matrixectomy the same day you come in for an evaluation of the nail.  Both procedures require you to get an injection of a local anesthetic to numb the toe.  This is a little painful, but much less painful than doing the procedure with no anesthetic.  Once the toenail is numb the physician will either remove the offending borders of the nail or if the nail is ingrown severe enough or badly damaged, they may need to remove the entire nail.  If you are only doing the temporary procedure, then this is the last step, and a dressing is applied.  For a permanent procedure, the physician at this point will either treat the nail matrix with acid, a laser or will surgically cut out the cells.  Once that step is performed, they will apply the dressing.  You will more than likely have a tourniquet placed around the toe, this is to stop the bleeding and is necessary when using an acid. Too much blood can cause the acid to fail and the nail to regrow. After the procedure, the physician will apply a large dressing.  This is to help control the bleeding.  Nail beds are very vascular and will bleed a lot after the procedure.

What is your aftercare?  Every physician is different in the exact aftercare, but it should be very similar to what I do in my practice.  I have the patient remove the dressing later that afternoon or evening, wash the toe well daily with soap and water.  I will have them apply a wound gel that we dispense from our office with a band-aid.  They will do this daily over 7-10 days.  Then we start to have them leave the nails open, especially when at home and they can have their shoes off.  They can soak their toes in Epsom salts if there is a lot of drainages.  Drainage is normal after a matrixecotmy (permanent procedure) especially if acid or a laser was used.  The is normal and should be a clear brown to yellow drainage.  It will take a full four to six weeks for the nail bed to heal but every day you should see an improvement.

Anytime a procedure or surgery is performed there are risks.  The risks with an ingrown procedure are rare.  These risks can consist of an infection, a regrowing of the nail in an ingrown position, or something called a specula.  An infection is going to present with an increase in redness, this is going to be a bright angry red color and could extend up the toe towards the foot.  Having a purplish red-looking toe after the procedure is normal.  There will be an increase in drainage, this drainage should be a clear yellow to brown drainage.  If it is a creamy white and thick drainage this can be a sign of infection.  Or you may just have an increase in pain after a few days of no pain.  All those are signs of an infection and you need to call your physician.  The nail may re-ingrown.  Now we already discussed how with an avulsion this is a high risk, but sometimes we can see it even when a permanent procedure is performed.  This usually happens at times when there is a significant infection or inflammation present.  The last risk we can see is when a specula grows.  This is when a portion of the cells did not die, and it grows back a straight piece detached from the nail edge.  All these risks can be treated.  An infection will need antibiotics and wound care.  The other two complications would require a repeat of the procedure.

If your bathroom surgery has failed or you just want to get rid of your painful ingrown nails please call for an appointment.

– Dr. Lesley Richey Smith, DPM