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Practice tips. Managing infected ingrown toenails: longitudinal band method

Authors:
  
Ingrown toenails are a common problem that
cause inconvenience and pain and limit daily
functioning. Ingrown toenails usually occur on
the big toe but might also affect the lesser toes.
Ingrown toenails are most frequently seen in ado-
lescents and young adults, but are a common prob-
lem for people of all ages.
Ingrown toenails can have three stages. During
stage 1, there is erythema, trace edema, and pain at
the lateral nail fold. During stage 2, there is increased
pain, discharge from the edge of the nail, and signs of
bacterial paronychia. In stage 3, hypertrophic granu-
lation tissue forms on the lateral wall.1
Causes
The etiology of ingrown toenails includes direct
trauma to the toe that forces the nail corners into
the surrounding nail fold, genetic predisposition,
improper nail trimming, poorly tting shoes, and
constant and repetitive microtrauma from normal
day-to-day activities.
Treatment
Treatment options range from conservative mea-
sures to surgery. Conservative approaches, includ-
ing soaking the foot in warm water, use of topical
or oral antibiotics, teaching proper nail-trimming
technique, and elevation of the corner of the
nail, are often used for patients with mild stage
1 disease.1 Patients can be prescribed antibiotics
that cover Gram-positive organisms; diabetic and
immunocompromised patients might need broader-
spectrum antibiotics. Family physicians can pack
the nail border with antibiotic-impregnated gauze
to relieve the pressure and to aid the nail to grow
out from the surrounding skin.
Surgical options include resection of the
affected nail border back to the nail matrix or
avulsion of the entire nail plate. Either surgi-
cal option can be followed with a matrixectomy
(removal of the nail matrix), which prevents
future growth of the nail. Matrixectomy can be
accomplished through chemical application, sur-
gical dissection, or electrocautery.2-4
For most cases, conservative treatment in the
form of basic foot care and advice about footwear
is adequate to relieve symptoms. When the prob-
lem is recurrent, health professionals often view
surgery as the best treatment to remove perma-
nently either the whole nail or just the troublesome
portion of the nail. Current conventional surgical
treatments are unsatisfactor y, however, because
ingrown nails have a high recurrence rate.2,5,6 Local
infection seems to be a predisposing factor for
recurrence after surgery.6
In this paper, we describe a new method for
treating stage 2 and 3 infected ingrown toenails.
We believe that all the problems mentioned above
(especially recurrence) could be solved by the
longitudinal band removal method.
Managing infected ingrown toenails
Longitudinal band method
Recai Ogur, MD Omer Faruk Tekbas, MD Metin Hasde, MD
Drs Ogur, Tekbas,Hasde

Practice Tips
VOL 5: FEBRUARY • FÉVRIER 2005 dCanadian Family Physician • Le Médecin de famille canadien 207
  
Main steps in the longitudinal
band removal method
Disinfect the ingrown nail and surrounding area
with an appropriate chemical antiseptic.
Apply local anesthesia with ethyl chloride spray
(for some patients we injected a mixture of lido-
caine and epinephrine 1:100 000).
Draw two parallel longitudinal lines on the centre
of the nail with a surgical knife to use as a guide
for the rest of the procedure (distance between
lines should be 4 to 5 mm).
Using an appropriate suture holder and surgical scis-
sors, remove the piece of nail between the two lines
(we have used a surgical knife instead of scissors, but
it seemed to cause more bleeding) (Figure 1).
Excise all the nail between two lines, but not the
part under the skin at the base.
Drain the abscess with an appropriate lancet or
surgical knife.
Dress the toenail with antiseptic dressing and
local antibiotic cream. Keep the dressing on for
3 days. Replace it daily.
Postoperative care
We ask patients not to wear shoes for 3 days and
recommend systemic broad-spectrum antibiotics
and nonsteroidal anti-infl amatory drugs for 10 days.
We do not recommend any particular drugs. We
evaluated the method in more than 50 patients for
about 10 months. Responses to a survey of patients
after treatment are shown in Table 1.
Only one patient had a recurrence of the con-
dition during the follow-up period. Because that
patient had a fungal infection, we now use this
method only after appropriate treatment for fun-
gal infections. We believe recurrence was related to
the anomalous shape of the nail that resulted from
the fungal infection.
Conclusion
We used the longitudinal band removal method
for all cases of stage 2 and 3 ingrown nails after
patients’ approval. Major advantages of the method
revealed by our study were that the surgical pro-
cedure is easy to perform and does not require
specialized equipment, that the operation can be
performed despite concomitant infection, that the
recurrence rate is low, and that postoperative pain
and limitation of daily functioning is minimal.
Acknowledgment
Dr Ogur’s
References
1. Zuber TJ, Pfenninger JL. Management of ingrown toenails. 1995;52(1):181-90.
2. Abby NS, Roni P, Amnon B, Yan P. Modifi ed sleeve method treatment of ingrown toenail.
 2002;28(9):852-5.
3. Lin YC, Su HY. A surgical approach to ingrown nail: partial matricectomy using CO2 laser.
 2002;28(7):578-80.
4. Zuber TJ. Ingrown toenail removal.  2002;65(12):2547-52, 2554.
5. Gerritsma-Bleeker CL, Klaase JM, Geelkerken RH, Hermans J, van Det RJ. Partial matrix excision
or segmental phenolization for ingrowing toenails.  2002;137(3):320-5.
6. Rounding C, Hulm S. Surgical treatments for ingrowing toenails. 
2000;(2):CD001541.
We encourage readers to share some of their practice
experience: the neat little tricks that solve difficult
clinical situations. Canadian Family Physician pays $50
to authors upon publication of their Practice Tips. Tips
can be sent to Dr Tony Reid, Scientifi c Editor, Canadian
Family Physician, 2630 Skymark Ave, Mississauga, ON
L4W 5A4; fax (905) 629-0893; or e-mail tony@cfpc.ca.
Practice Tips
Table 1. Recovery time after treatment
STAGE OF RECOVERY AVERAGE TIME
Recovery from pain and wound exudates 24-48 h
Beginning to wear shoes End of 3rd d
Continuing normal activities End of 3rd d
Infection cured 7-8 d
Nail pieces begin to knit 10-14 d
Nail pieces begin to fuse by forming a midline scar 6th wk
Figure 1. Longitudinal band removal: 
   


208 Canadian Family Physician • Le Médecin de famille canadien dVOL 5: FEBRUARY • FÉVRIER 2005
... A central strip of nail, 4 to 5 mm wide, may be removed without any incision into the soft tissue of the nail folds or nail bed [38]. This takes the outward pressure of the nail plate away and-according to the authors-allows the nail to grow out without piercing into the lateral grooves. ...
... This takes the outward pressure of the nail plate away and-according to the authors-allows the nail to grow out without piercing into the lateral grooves. It permits normal activities after about 3 days [38]. However, this should be accomplished with gauze or cotton packing in order to free the nail spicule from the nail groove. ...
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Ingrown toenails are one of the most frequent nail disorders of young persons. They may negatively influence daily activities, cause discomfort and pain. Since more than 1000 years, many different treatments have been proposed. Today, conservative and surgical methods are available, which, when carried out with expertise, are able to cure the disease. Packing, taping, gutter treatment, and nail braces are options for relatively mild cases whereas surgery is exclusively done by physicians. Phenolisation of the lateral matrix horn is now the safest, simplest, and most commonly performed method with the lowest recurrence rate. Wedge excisions can no longer be recommended.
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