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A case report of ingrown toe nail
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Onychocryptosis is prevalent globally and most often the result of self-attempts at curing the condition in its earliest stages. Its clinical presentation is often confused with a number of osseous and soft tissue abnormalities, some of which have great import to a patient's overall welfare. Treatment consists of local and systemic care, including nail avulsion. Recurrences are reduced when some form of matricectomy is used. Matricectomy techniques vary and must be selected on the basis of caregiver and patient preference. Although the chemical matricectomy is popular, care must be exercised in selecting patients for its use.
Onychocryptosis is a pathologic condition of the nail apparatus in which the toenail damages the nail fold. It is a common condition provoking pain, inflammation, and functional limitation. It principally occurs in the hallux. Onychocryptosis is one of the most frequent complaints regarding the foot and accounts for many clinical consultations. The disorder has been classified in terms of the stages of the pathologic condition. In our practice, we discovered a clinical entity that was not previously classified in the literature. We classify onychocryptosis into stages I, IIa, IIb, III, and the new stage IV. A treatment plan is offered for each stage of this classification, with both general and specific indications given. In onychocryptosis treatment, it is important to select the surgical technique best suited to the patient's particular clinical situation.
Merkel cell tumor (MCT) typically occurs on the head or neck of elderly patients. A case is presented of a teenage girl with an MCT on her toe. The diagnosis was made 5 years after an ingrown nail on the toe was avulsed. During the interim 5 years, the periungual skin looked like granulation tissue and thus no biopsy was performed. This case of MCT is unique in three aspects: (a) extraordinarily young age, (b) atypical site, and (c) deceptive clinical appearance. Awareness of the possible occurrence of MCT in younger patients and in unusual locations will facilitate earlier diagnosis.
Ingrowing toenails are a very common condition that has a significant associated morbidity. Although treated by practitioners of many specialties, most doctors have minimal training in this area. In this overview, an algorithm will be used to direct in an efficient and pain minimizing way the management of recalcitrant ingrowing nails.
Proper presurgical preparations are presumed to eliminate organisms from the skin, nails, and nail grooves. It has not been documented as to whether surgical scrubs reduce the types and numbers of bacteria and thereby affect the incidence of infection in performing toenail surgery. This study, performed pre- and postsurgical scrub cultures of four sites on 40 subjects. Similar cultures from ten additional patients who underwent nail surgery were also performed. The later set had an additional set of cultures performed after avulsion of the nail plate and the beginning of the actual surgical procedure. Blood cultures were done intraoperatively on the surgical patients. Results revealed that nail grooves are difficult, if not impossible, to antisepticize. The usual presurgical scrub does not eradicate bacteria in these areas. As such, nail surgery must certainly be considered dirty surgery and precautionary measures must be considered.
The phenol and alcohol procedure still remains as one of the most effective and gratifying means of treatment for symptomatic ingrown nails. Most of the literature is concerned with length and manner of application and various forms of postoperative management. Several points must be stressed. In order to be effective, the procedure must be performed in a bloodless field. In lieu of using a tourniquet, a mixture of lidocaine-epinephrine 1:100:000 has been found to be an appropriate way to attain hemostasis. We have not experienced any complication to date. A partial procedure should be performed whenever the remaining nail plate may become symptomatic. Concerning the length and manner of application, the times presented should be used as an average. The application should be based on an observation of tissue change. In general, we have found it more favorable to overapply, rather than risk the chance of recurrence. Preoperatively the patient is fully advised of the projected postoperative period and understands that this will eventually coincide with a more favorable result. Following removal of the offending nail border, we advocate aggressive curettage of the nail groove and matrix cavity. The fresh phenol is applied with pressure within the nail groove, matrix, and roof of the matrix. The use of an alcohol flush serves as a mechanical irrigation rather than a neutralizing agent. The incorporation of Adaptic serves as a drain which is removed on postoperative day 1 along with the accumulated coagulum. This removal of necrotic tissue will facilitate drainage. The patient is instructed to soak in a betadine, salt water solution followed by the application of cortisporin otic solution and dry sterile dressing. The cortisporin otic solution serves as an antimicrobial and anti-inflammatory topical agent. The soaking and cortisporin regimen continue until healing is achieved. Overall, we have found the phenol-alcohol matrixectomy to be simple and gratifying to perform. The procedure is virtually pain free and nondisabling to the patient.
A simple method of treating ingrown toenails by conservative ablation of nail plates and chemocautery of matrices is described and illustrated.
Athletes are susceptible to developing toenail problems because of the speed or intensity of play (runners), the starting and stopping nature of the sport (tennis, racquetball), and the type of activity and shoes they wear or do not wear (ballet dancers, gymnasts). They may also have other conditions, such as hallux valgus, claw toes, gout, diabetes, arthritis, or fungus infection of the nails, that may influence the decision on the type of treatment recommended. Nail trauma that could result in osteomyelitis; secondary effects of arthritis, such as the development of a mucous cyst; and the infected ingrown toenail are seen frequently in the athlete and can be satisfactorily treated by the orthopedist.
A wide variety of generalists and specialists treat locally infected ingrown toenails, with perhaps the most common treatment regimen including resection of the nail border coupled with oral antibiotics.
To determine whether oral antibiotic therapy is beneficial as an adjunct to the phenol chemical matrixectomy in the treatment of infected ingrown toenails.
We prospectively enrolled healthy patients with infected ingrown toenails. Each patient was randomly assigned to 1 of 3 groups that received either 1 week of antibiotics and a chemical matrixectomy simultaneously (group 1), antibiotics for 1 week and then a matrixectomy (group 2), or a matrixectomy alone (group 3).
Institutional ambulatory outpatient clinic.
Fifty-four healthy patients with infected ingrown toenails were studied. Patients with immunocompromised states, peripheral vascular disease, or cellulitis proximal to the hallux interphalangeal joint were excluded. Groups were age matched for comparison.
Mean healing times for groups 1, 2, and 3 were 1.9, 2.3, and 2.0 weeks, respectively. Subjects receiving antibiotics and a simultaneous chemical matrixectomy (group 1) healed significantly sooner than those receiving a 1-week course of antibiotics followed by a matrixectomy (group 2). There was not a significant difference in healing time between those that received a chemical matrixectomy alone (group 3) and those that received a matrixectomy coupled with a course of oral antibiotics (group 1).
The use of oral antibiotics as an adjunctive therapy in treating ingrown toenails does not play a role in decreasing the healing time or postprocedure morbidity.
There are four main types of ingrown nail. These are distal nail embedding, juvenile (subcutaneous) ingrown nail, hypertrophy of the lateral nail fold (lip), and pincer nail.
The etiology of pincer nail may be hereditary or acquired. The mechanism of the most common form, an enlarged base of the distal bony phalanx, is discussed.
Use of roentgenogram and magnetic resonance imaging highlights exophytes of the base and dorsal hyperostosis of the distal phalanx.
Global assessment may lead in mild cases to medical therapy. Usually, however, the lateral matrix horn must be surgically removed or cauterized by phenol. Dermal grafting under the nail matrix provides excellent long-term results.
Partial excision of the nail matrix (matricectomy) is generally considered necessary in the surgical treatment of ingrown toenail. Recurrences may occur, however, and poor cosmetic results are frequently observed.
The objective is to present a new surgical procedure for ingrown toenail with complete preservation of the nail matrix.
Twenty-three patients with ingrown toenail were included in this study. The surgical excision was performed 1 week after the completion of treatment of the initial infection. A large volume of soft tissue surrounding the nail plate was removed under local anesthesia. No matrix excision was performed.
Short-term results were excellent. No recurrences or severe complications were observed during the minimum 12-months follow-up period. Cosmetic results were remarkable.
Ingrown toenail results from the compression of the lateral nail folds on the nail plate. This study shows that ingrown toenail can be surgically treated without matricectomy. A large volume of soft tissue surrounding the nail plate should be removed to decompress the nail and reduce inflammation. Cosmetic results are excellent and superior to the classical Emmert plasty. Postoperative nail dystrophies and spicule formation are not observed. The main advantage of this surgical approach is the complete preservation of the anatomy and function of the nail to improve both therapeutic and cosmetic results.
Nail avulsion plus chemical matrixectomy (CM) using NaOH as an alternative to surgical matrixectomy (SM) has recently been used in the treatment of ingrown toenails (IGTNs) in adults. No studies exist to dictate the most effective and safe treatment method in the pediatric population.
A retrospective review of pediatric IGTNs treated at 2 institutions for 6 years was done, looking at presentation, treatment modality, SM vs CM, and outcomes.
Eight hundred forty-eight IGTNs in 518 patients were reviewed with an average age of 12.5 years. Twenty-three percent were felt to be infected at the time of presentation, and 34% were being treated with antibiotics within the preceding week of surgery. Seventy-nine percent of toenails underwent surgical management with the most common procedure being avulsion plus SM (65%), followed by avulsion plus CM (17%), and avulsion alone (14%). The overall recurrence rate after initial surgery was 19.5%. After adjusting for covariates, recurrence was associated with treatment by avulsion alone (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.5-4.7), avulsion plus CM (OR, 0.3; 95% CI, 0.1-0.7), and treatment with antibiotics within the week before surgery (OR, 0.5; 95% CI, 0.3-0.9; P = .017). The overall postoperative infection rate was 6% and was unrelated to presence of preoperative infection, use of antibiotics, or surgical treatment method.
Ingrown toenails present a significant problem to youth and should be addressed in a diligent fashion. Chemical matrixectomy using NaOH is a safe and effective alternative to SM and maybe associated with a lower rate of recurrence, especially when use in conjunction with preoperative antibiotics.
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