Ingrown toenails (onychocryptosis): Management

Visits: 878

Ingrown toenails are a common problem in primary care practices, About 20% patients presenting to GP with a foot problem have an ingrown toenail, also known as onychocryptosis. It occurs when the peri-ungual skin is punctured by its corresponding nail plate, resulting in a cascade of foreign body, inflammatory, infectious, and reparative processes. Ultimately, this may result in a painful, draining, and foul-smelling lesion of the involved toe (most commonly, the great toe nail), with soft tissue hypertrophy around the nail plate.

Many factors contribute to abnormal toenail growth and ingrown toenails including anatomic variations such as wider nail folds and thinner, flatter nails. In addition, genetics, family history, hyperhydrosis, trauma, and poor foot hygiene may also promote ingrown toenails. Diseases like diabetes, obesity, as well as thyroid, cardiac, and kidney diseases that promote lower extremity edema can contribute to a higher risk for ingrown toenail. However, available clinical data support most of these factors are risks for ingrown toenails.

Clinical Feature:

Mild ingrown toenails are characterized by nail-fold swelling, erythema, edema, and pain with pressure; may be treated with conservative management. Moderate ingrown toenails demonstrate increased swelling and sero-purulent drainage. Severe cases exhibit chronic inflammation and granulation, along with significant nail-fold hypertrophy. Moderate and severe ingrown toenails should be considered for prompt surgical management.

Treatment considerations:

Conservative therapy includes soaking the affected toe in warm, soapy water for 10 to 20 minutes. Soaks may be followed by application of a topical antibiotic ointment or mid-potency to high-potency steroid cream. Patients may also manage mild ingrown toenails by placing wisps of cotton or dental floss under the lateral edge of the ingrown nail. This practice may immediately reduce pain and does not appear to increase the risk for infection if done in an aseptic way.

Adjunctive systemic antibiotics are usually unnecessary for patients receiving partial avulsion of the nail edge and matricectomy. Patients should be instructed before the procedure that the appearance of the affected nail will be permanently altered and that the recess created by the removal of the nail and granulation tissue will gradually resolve to a somewhat normal appearance. Antibiotics do not improve outcomes between ablation of the nail bed and phenolization. Partial nail avulsion followed by phenolization is equally as effective as direct surgical excision of the nail matrix. Excessive application of phenol could result in prolonged oozing of the toenail wound.

Some authors recommend brief application of a tourniquet during nail avulsion as promote in cutting the affected part of the nail with a hemostat before removing the nail.

Patients may soak the affected foot 24 to 48 hours after the surgery and then apply antibiotic ointment and a new bandage. This postoperative care should be continued 3 to 4 times daily for 1 to 2 weeks after the procedure.