Ingrown Toenails

DEFINITION

from Surgery of the Foot, 5th edition, edited by Roger A Mann page 416 (Unguis incarnatus):

Diseases and deformities of the great toenail are generally grouped under the lowly term ingrown nail and are treated empirically. Because of the lack of differential diagnosis and understanding of the diagnosis, in numerous instances these patients are subjected to a series of unsuccessful operative procedures that often produce more complicated problems than the original disease, including recurrence and consequent iatrogenic (caused by the treatment) deformity.

What is going on:

Pain, swelling, infection, and discharge result from a breakdown in the normal relationships between the toenail and the adjacent tissue, specifically the portion of toe that lies next to the nail called the "nail lip". Often the onset of the trouble is a stepped on toe or other trauma where the nail is forced into the flesh of the toe, breaking the nailbed or delicate covering of the nail groove. The broken tissue, especially if subjected to a series of trauma, becomes infected. The result is pain, swelling, and discharge of pus. Because of the imperative to wear shoes in our culture, swelling results in pressure (caused in part by the shoe) and this aids and abets the pain and interferes with a normal blood flow locally that would promote healing. If the infection continues long enough "proud flesh" or granulation tissue develops which adds to the problem by increasing the toe mass under or next to the nail which increases the pressure between the nail and the flesh of the toe which tends to continue and aggravate the infection. In twelve years of medical practice in Africa, the author has never seen an ingrown toenail in barefoot peoples.

What to do:

1. The first thing to do is to give the toe some space and to help nature overcome the infection. If for reasons of weather or social or cultural pressures it is not possible to wear open-toed sandals, perhaps the patient should stay home in order to go barefoot until the infection is healed.

2. The best help in overcoming the infection is to do alternate hot and cold foot soaks using epsom salts in the hot water. Local heat will have the effect of making it feel better while promoting healing. Alternate hot and cold applied locally will increase the blood flow to the part and have the effect of "washing out" the collection of pain chemicals while bringing in the needed repair substances. Heat will ease the pain help reduce swelling allowing for more normal local blood flow. The best way to apply hot and cold to the foot (e.g. 3 min hot and 1/2 min cold): is with two basins or buckets of water. Use a thermometer to measure the heat of the hot water. Start the hot water about 100F (37.7C) and increase the temperature by adding more hot water (without burning yourself) to a maximum temperature of 110F (43C). Add ice to the cold water to keep it cold and end the treatment with cold (at least three hots and three colds). If you have diabetes, peripheral neuritis, or other disease that makes your body part insensitive to temperature consult your professional medical providers before attempting to use hot and cold on yourself. Into the hot water pour epsom salts (obtained from a drug or department store) while stirring until it stops dissolving. Now you have a "supersaturated solution" and that is what is needed to "draw out" the infection because the osmotic pressure in the supersaturated epsom salt solution is greater than in the body tissues of the toe. Use ordinary cold water without epsom salts for the cold soak. This can be done several times a day depending upon how severe the infection is. Triple antibiotic ointment (obtained "over the counter") will also help control the infection. Local treatment will usually take care of the infection with no risk of any side effects - as long as you do not burn yourself with the hot water!

3. At this point a decision needs to be made. The two choices are to treat the nail further yourself by packing the nail with disinfectant soaked cotton. A small amount of cotton wool soaked in some disinfectant like Betadine (Provedant iodine) is introduced under the nail to get the edge of the nail out from digging into the flesh and to allow it to grow out. This will be effective if the cotton wool is kept in place (may need to be replaced daily for several weeks) until the nail grows out normally. This is the best outcome. For various reasons this treatment is not favored or performed by most patients. The alternative is to seek professional medical advice.

4. A word of caution: It is almost always successful in the short term and almost always not successful in the long term to simply cut the edge of the nail. Whether you do it yourself or a family member or your professional medical service, the results will likely be the same. The reason for the failure of this kind of treatment is that the nail as it grows out usually gets driven into the flesh of the toe. This is more likely than not because the nail has been cut, leaving the nail groove empty beyond where the nail was cut. The more successful surgery is to have the nail margin, nail bed margin and that portion of the margin of the root of the nail along with the excess nail lip - the entire block of tissue - excised. This surgery (attributed to Winograd in 1929) is over 95% successful. The 5% regrowth of the nail can be re-excised if necessary.

The other surgery that is always successful (almost always!) is simply to remove the nail and the nail bed so that the toenail does not grow back again. There are several disadvantages with this procedure. It takes about a month to heal. The toe is always not cosmetically pleasing. A plastic toenail to make it look better may be glued on, however this is a lot of repetitive work. The proprioception (sense of position and pressure) given to the end of the toe especially with regards to pressure sensation is greatly impaired without a toenail.

5. Prevention: Ingrown toenails cannot always be prevented, however certain things will help: a) cut the nails so that the nail extends beyond the end of the flesh of the toe. Do not cut the toenails too short. b) Wear shoes and socks that give the toes room. c) If the flesh of the toe gets damaged e.g. by being stepped on, do prophylactic hot and cold soaks to prevent infection.