What is an ingrown toenail?

Ingrown toenails also known as unguis incarnatus, or onychocryptosis, is a common problem, where the edge of your toenail grows into the surrounding skin, causing pain, redness, and in some cases infection of the toenail. The sharp edge of the toenail digs into the skin instead of growing out resulting in the pain and redness experienced by you!

The big toe is most commonly affected, with the outer edge being involved more often than the inner side. This condition is seen in people of all age groups but affects men more commonly than women.

What causes ingrown toenails?

A multitude of factors contribute to the development of ingrown toenails, and they are most commonly affected by poor nail cutting, and external pressure on the toenails.

Improper nail cutting: When the nails are trimmed until it is extremely short, or the corners are cut in a rounded fashion, the sharp edges of the trimmed nail can penetrate the skin of the toes causing inflammation and pressure necrosis. The proper way to trim the toenail to reduce the incidence of ingrown toenails is to cut it straight beyond the nail bed.

External pressure: Narrow and pointed shoes, although fashionable, are a leading contributor to ingrown toenails. Shoes that are too tight result in the compression of the skin against the stiff nail edge, turning the nail into a cutting surface and damaging the skin.

Other contributors to ingrown toenails include injury of the toenail, obesity, diabetes, onychomycosis (fungal infection of the nail), and hereditary inwardly curved nails.

What are the symptoms of ingrown toenails and why do they happen?

Pain is the most common symptom of an ingrown toenail. The pain is usually significant and worsens with walking and putting pressure on the affected toe. The pain is localized to the affected toenail and is often associated with crusting, pus, and friable skin. Some patients also report the overgrowth of skin tissue at the edge of the toes, resulting in the toenail being covered by the skin.

When the nail plate does not fit into the nail groove, it causes the sharp edges on the nail margin to dig into the skin causing a foreign body reaction. This foreign body reaction causes an inflammation response which results in pain, redness, purulence, and the development of granulation tissue.

What are the complications of an ingrown toenail?
Infection of the toenail (paronychia) with surrounding skin infection (cellulitis) is a common complication of ingrown toenail.

If proper treatment is not administered, and the condition is allowed to fester, an abscess (collection of pus) can form, and in severe cases, the infection can affect the bone causing osteomyelitis (bone infection) which may require amputation of the affected toe to treat the condition.

Recurrence is a common complication affecting 10-30% of the cases of ingrown toenails that have been treated. A Cochrane review has shown that surgical interventions are more effective in preventing recurrence compared to nonsurgical treatments.

What is the treatment for ingrown toenails?

In mild cases of ingrown toenails, non-surgical treatment methods such as those described below can be considered:

• Trimming of the nail spike by a podiatrist with special nail clippers to provide pain relief.
• Regular trimming of the nail and application of cotton packs along the nail border to reduce recurrence.
• Use of toenail braces to straighten curved nails.
• Antiseptic foot soaks to prevent infections.

Unfortunately, these treatment methods often fail and definitive toenail surgery would be required. This would typically involve partial nail avulsion followed by matricectomy to reduce the risk of recurrence.

Partial nail avulsion

This procedure involves making a vertical incision along the length of the affected toenail and removing a part of the toenail that is causing the symptoms of pain and redness. Removing the affected part of the toenail alone is insufficient, as the nail matrix is still intact. The nail matrix, which is found at the base of the toenail, is responsible for making cells that would become future toenails and it has to be removed to prevent recurrence.

Matricectomy

This procedure is the process of removing the nail matrix, an essential step to be performed during ingrown toenail surgery, to prevent ingrown toenail recurrence. This can be performed used chemical methods or surgical methods.

Phenol matricetomy

Phenol (C6H6O or C6H5OH) is an organic compound that is colourless to light-pink that is commonly used as an antiseptic, disinfectant, and to manufacture products. Phenol solution at a concentration of 88% is the most commonly used chemical agent for matricectomy, and it is considered a gold standard treatment in the management of ingrown toenails.

Surgical matricetomy

This method of matricectomy involves the use of a curette and electrocautery to remove the nail matrix. Curettage is a medical procedure where a surgical instrument is used to scrape away unwanted or unhealthy nail matrix to reduce the recurrence of ingrown toenails. An Electrocautery tool is a medical device that we use to pass an electrical current through the tissue to heat the tissue, destroying any remnant nail matrix that can contribute to an ingrown toenail. Electrocautery is a useful tool in our armamentarium to stop bleeding after partial toenail avulsion, a common complication during toenail surgery.

What we do in The Clifford Clinic

At The Clifford Clinic, we believe in employing treatments that are industry standards with refinements to achieve superior results.

Before the surgery is performed, the affected toe is sterilized with povidone-iodine and chlorhexidine to create a sterile environment for the procedure. Local anesthesia is then injected around the affected toe to ensure that there is minimal pain during the actual procedure itself. Subsequently, a tourniquet is applied around the toe to reduce the risk of bleeding during the procedure.

Thereafter, the affected portion of the ingrown toenail is elevated and excised using a nail cutter. After the affected portion of the ingrown toenail is cut, it is then removed exposing the nail matrix. A curette is used to scrape off any unwanted and remnant nail that can contribute to recurrence. A cotton-tipped applicator soaked with phenol is then placed into the nail bed that has been exposed after the removal of the nail to kill off the nail matrix that would contribute to recurrence. The wound is then rinsed with alcohol to neutralize the phenol solution.

A unique step in the Clifford Clinic is the use of electrocautery. The wound is then inspected for viable nail matrix that was not removed by the phenol solution, electrocautery is then used to remove any remnant nail bed, further reducing the chance of recurrence. The tourniquet is then removed, and any bleeding identified during this step is promptly stopped with electrocautery.

The wound is cleaned once more before a dressing is applied to the wound.

Complications of ingrown toenail surgery

Ingrown toenail surgery is generally a safe procedure without major complications, however, some of the common complications include:

• Infection: This is the most common complication, which can happen even with proper hygiene and wound care. This is more common in patients with compromised immunity such as patients with diabetes. It can present with excessive pain, redness, and swelling of the wound. In severe cases, patients would require a course of oral antibiotics.
• Pain and discomfort: Pain is expected after the surgery, and in some cases, oral painkillers may be required to reduce the pain. Some other pain management strategies include elevating the affected foot whenever you are sitting down or sleeping to reduce swelling which contributes to pain and discomfort.
• Delayed healing: In some cases, patients may experience that the wound takes longer than normal to heal.
  Bleeding: Though uncommon, excessive bleeding can occur and it is a traumatizing experience for patients. In the Clifford Clinic, we take the necessary precautions to minimize this with a tourniquet before excising the nail, and using the electrocautery to stop any bleeding after the surgery.
• Recurrence of Ingrown: Even after ingrown toenail surgery, it is still possible to get ingrown on the affected toe. In the Clifford Clinic, after partial nail avulsion, we combine both chemical and surgical matricectomy to reduce the risk of recurrence. In this post, we will also elaborate on how you can further reduce the odds of recurrence.

What is the aftercare?

The aftercare following ingrown toenail surgery is essential for proper healing and to minimize the risk of complications. Here is a comprehensive guide on the post-operative care after ingrown toenail surgery:

• Keep the affected foot elevated

Elevate the affected foot as much as possible after the surgery, especially for the first few days. This step helps to reduce swelling which contributes to the pain and discomfort after surgery. Elevating the leg also helps to improve blood circulation and promote wound healing.

• Wound hygiene

Please keep the wound clean and dry. If you need to shower, wrap up the area to prevent it from getting wet. If the dressing is soaked, consider changing the dressing to prevent infection, which would delay the healing process. Please follow the dressing change advice provided by the doctors and healthcare providers in the clinic.

• Managing pain and discomfort

Pain and discomfort after surgery are inevitable, therefore, oral painkillers will be prescribed. The painkillers prescribed would be sufficient to manage the pain. However, if there is severe pain that is not managed with the prescribed analgesia, please drop by the clinic for a review.

• Proper footwear

Immediately after surgery, choose footwear that provides ample room for your toes to heal, and avoid tight or restrictive footwear. Choose open-toed shoes such as scandals to avoid applying unnecessary pressure on the surgical wound.

• Limit activity and protect the toe

After the surgery, you would want to avoid strenuous activity, or excessive walking as this results in increased swelling of the affected toes, and puts you at risk of bumping your toes. If you need to do any physical activity or have to head outdoors, ensure that the wound is covered up with a dressing to reduce the risk of infection.

• Monitor for complications

Complications can happen and knowing the symptoms are important in early identification and treatment. Common signs and symptoms include persistent pain not controlled by oral painkillers, excessive bleeding, fever, and pus. If you experience any of these symptoms please contact our clinic stuff for an early review.

How do I prevent ingrown toenails?

Ingrown toenails are unpleasant and painful, the surgery is also a daunting experience; hence proper foot care habits are vital in preventing ingrown toenails in the future. Some of the effective strategies you can employ for preventing ingrown toenails include:

• Trim your toenails correctly

Cut your toenails straight across, and avoid rounding the edges. When the toenails are trimmed too short or the edges rounded, the jagged edges of the nail can dig into the skin causing ingrown.

• Proper footwear

Choose shoes with a wide toe box allowing sufficient space for your toes to wiggle around comfortably. Tight-fitting shoes with a narrow toe box result in excessive pressure on the toenails and cause the nail edge to cut into the skin, increasing the risk of ingrown toenails.

• Good foot hygiene

Fungal infection is one of the causes of ingrown toenails, therefore, it is paramount to keep your feet clean and dry, especially between the toes, to prevent fungal infection of the toes.

• Protecting your toes

Toenail trauma is another leading cause of ingrown toenails. If you engage in sports or activities that put you at risk of injuring your toenails, consider wearing protective footwear such as boots to reduce the risk of toenail injury.

• Address early signs of ingrown toenail early

If there are any signs of ingrown toenail such as pain, redness, or swelling, address it promptly to prevent it from worsening.

By incorporating these preventive measures into your daily routine, we hope you can reduce the risk of developing ingrown toenails and keep your feet happy and healthy.

Conclusion

An ingrown toenail is an unpleasant, painful, and common problem. In the Clifford Clinic, we employ techniques to treat your ingrown toenail and minimize recurrence. If you have any questions on how to manage your ingrown toenail, book a consultation with us, we would be grateful for the opportunity to treat your ingrown toenail and let us work towards having happy healthy feet.