Ingrown nails

Author : Dr Philippe Abimelec
Last scientific update : December 2016

YOURS QUESTIONS ABOUT INGROWN NAILS

What is an ingrown nail ?

Ingrown nails are due to a fragment of nail penetrating into the flesh and causing inflammation and pain.

What causes ingrown nails ?

• The factors responsible for ingrown nails are many, varied and sometimes interrelated.
• Family or genetic predisposition responsible for a malformation of the nail.
• Poorly fitting shoes (too small).
• Inadequate foot care (nails trimmed too short in the corners).
• Certain drugs (acitretin used to treat psoriasis or protease inhibitors against HIV infection).
• Bone changes secondary to arthritis.
• An outgrowth of flesh developing under the nail.

Who is at risk of developing an ingrown nail ?

Infants and toddlers may present several types of ingrown nails
– Hypertrophy of the lateral nail folds leads to the thickening of a fold of flesh along the side of a big toenail.
– Malformation of the big toenail which is thick, striated, detached from the nail bed and sometimes deviated. This nail falls off and grows into the flesh at the distal part of the toe.
– Newborn pincer nail which is curved on both sides tending to meet.

Teenagers and adults develop what is called the “common ingrown nail” or “juvenile ingrown nail”.

Seniors develop pincer nails which sometimes mean that there is an outgrowth developing under the nail.

Anterior ingrown nail – After the nail has fallen, there can be an ingrown nail when the nail penetrates into the flesh at the distal part of the toe.

What are the symptoms of ingrown nails ?

The nail grows into the flesh (the ingrown part)
– On the side (the common ingrown nail): the lateral nail fold is painful when pressed and during walking.
– At the front (anterior ingrown nail): the nail penetrates into the flesh at the front of the nail fold, it is impossible to cut it out and the nail often ends up falling.

Pain, redness and swelling (inflammation) which sometimes precedes infection with formation of a whitlow (abscess of the nail) or erysipelas (more serious infection of foot or leg tissue due to a streptococcus).

Thickening of a nail fold (hypertrophy of a lateral fold).

Red flesh outgrowth (pyogenic granuloma).

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Ingrown nails in young children or Abnormal positioning of the big toes
Juvenile ingrown nail
ingrown nail in seniors or Pincer nail

How can one diagnose an ingrown nail ?

A simple examination by an experienced physician suffices to diagnose an ingrown nail.

What treatments are available for ingrown nails ?

Medical care

Infants and young children
– The hypertrophy of the lateral nail folds: it can self-heal and requires no treatment in general.
– The congenital malformation of the big toe : it often gets better with age, but the nail can fall each time it grows back or remain deviated, corrugated and thickened. There can be a lateral or front ingrown nail requiring surgery. In some cases, it is possible to improve the aesthetics of the nail by surgery. Chiropody (nail trimming) or false nails can sometimes be useful. It is recommended to ask a specialist his or her opinion about the treatment most appropriate for your child.

Teenagers and seniors
Prevention
– Avoid cutting the nails in the corners whenever possible.
– Use appropriate antiseptics as soon as there is a sign of inflammation.
– See a chiropodist/podiatrist outside of the growing periods.
– Wear shoes that are wide enough.
Curative treatment
– Antibiotics and disinfectants (bathe your feet with an antiseptic product containing Chlorhexidin for example).
– Some chiropodists/podiatrists use metal or resin braces (nail corrective devices) to try and correct the problem, at least temporarily.

Anterior ingrown nail
It can be prevented by applying a false nail 3 to 4 months after the accidental fall of a big toenail. In case of infection, disinfectants and/or antibiotics must be prescribed.

Permanent surgery
Surgery often becomes necessary in case of frequent relapses.

Traditional surgery
• Following injection of a local anaesthetic at the basis of the toe and application of a small tourniquet, the surgeon removes with a scalpel one edge of the nail unit including the nail bed (part under the nail) and the nail matrix (which manufactures the nail). Stitches are required.
• Major disadvantages: post-operative pain, need to stop work for several days, failure rate of about 3 to 5 per cent

C02 Laser surgery
• Following injection of a local anaesthetic at the basis of the toe and application of a small tourniquet, the surgeon will remove the edge of nail growing into the flesh. He will then permanently destroy the portion manufacturing the ingrown nail by laser photocoagulation. Stitches are necessary.
• Disadvantages: post-operative pain due to the wound and scar.

Phenol Matricectomy – this is our surgical treatment of choice
• Following injection of a local anaesthetic at the basis of the toenail and application of a tourniquet, the surgeon will remove the edge of the nail growing into the flesh and cauterize the matrix area with phenol to permanently and selectively destroy the matrix manufacturing the ingrown portion of the nail.
• Advantages: the surgery can be performed in the doctor’s private practice under local anaesthesia, little or no pain following the intervention, no need to stop work, no visible scar.
• Disadvantages: the procedure will fail in about 2 to 3 times out of one hundred.

Frequently asked questions about ingrown nails

How can one avoid surgery for ingrown nails ?
Frequent visits to a chiropodist/podiatrist will often make it possible to postpone surgery for several years. Ingrown nails in infants often get better with age.

When is it time for surgery ?
In case of infection or of a fleshy outgrowth (granulation tissue) or in case of pain that podiatric care no longer relieves, all of these are indications that the time has come for you to get operated on.

Bibliography

1. Heifetz, C. J. Ingrown toe nail. A clinical study. Am J Surg 38, 298 (1937).
2. Van der Ham, A. C., Hackeng, C. A. & Yo, T. I. The treatment of ingrown toenails. A randomised comparison of wedge excision and phenol cauterisation. J Bone Joint Surg [Br] 72, 507-9 (1990).
3. Abimelec, P. Matricectolyse au phénol. Dermatologie pratique (1996).
4. Bouscarat, F., Bouchard, C. & Bouhour, D. Paronychia and pyogenic granuloma of the great toes in patients treated with indinavir [letter]. N Engl J Med 338, 1776-7 (1998).
5. Bostanci, S., Ekmekci, P. & Gurgey, E. Chemical matricectomy with phenol for the treatment of ingrown toenail: a review of the literature and follow-up of 172 treated patients. Acta Derm Venereol 81, 181-3 (2001).
6. Baran, R., Haneke, E. & Richert, B. Pincer nails: definition and surgical treatment. Dermatol Surg 27, 261-6. (2001).
7. Lin, Y. C. & Su, H. Y. A surgical approach to ingrown nail: partial matricectomy using CO2 laser. Dermatol Surg 28, 578-80 (2002).

Disclaimer: basic foot care can help prevent minor ailments from developing into serious ones. This article provides healthcare professionals with some useful guidelines to pass on to their patients concerning basic foot care. It should be noted, however, that these guidelines are intended for people with healthy feet and not for people who have diabetes or compromised circulation. Such patients should consult a foot healthcare professional for further guidance and treatment.
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