Management

Treatment of the condition is divided into those that occur:

• in normal nails
  • initial treatment should be conservative - patients should be advised about proper foot care and foot ware (1,2)
  • patient is told to cut the nail squat, to insert pledgelets of cotton wool under the ingrowing edges and to always keep the feet clean and dry. The cotton wool is designed to force the nail to grow over (and not into) the skin (2)
    • nail should be trimmed at right angles to the long axis of the toe
    • chiropodist can gently retract the nail fold and trim the offending nail spike
• in abnormally wide or incurvated edge toenails
  • surgical intervention may be necessary
  • should be offered partial nail avulsion with segmental phenol ablation
  • total nail avulsion - for patients with severe involuted nails on both the tibial and fibular sides (pincer nails)
• secondary infection is treated with antibiotics (topical or oral antibiotics depending on severity of infection) (2)

Surgical options can be

• temporary procedure
  • includes procedures such as simple (or partial) nail avulsion without chemical or surgical ablation, simple (or partial) nail avulsion without chemical or surgical ablation
• permanent procedures
  • nail avulsion combined with phenol ablation is considered the treatment of choice
    • lower rates of recurrence have been reported compared with partial avulsion with nail matricectomy
    • recurrences are treated by repeat application of phenol
    • can be done even in the presence of acute infection

Partial nail avulsion with segmental phenol ablation (1)

• toe is cleaned with suitable skin preparation e.g. - povidone-iodine or chlorhexidine.
• a ring block of the affected toe by injecting 1% plain lidocaine is injected at the base of the toe and then a coloured ring tourniquet with a tag is applied
• following successful local anaesthesia the next step is to separate the edge of the appropriate nail plate from the soft tissues
  • a cut is made with a straight Beaver mini-blade to isolate an appropriate (usually 3-5 mm) section of the affected nail segment extending under the proximal nail fold, which is lifted off by grasping with an artery clip and using a central to lateral twisting motion to avulse the germinal centre
• paraffin jelly is applied to the surrounding skin for protection
• phenol is applied for one minute usually twice which is then followed by a washout with normal saline
  • before applying alcohol, good haemostasis should be achieved to facilitate proper matricectomy
• postoperative dressing is applied for 48 hours after which it is removed and the foot is soaked in tepid salt baths daily - it prevents infection caused by accumulation of debris in the nail folds
• patients can return to work the following day but must be warned about the possibility of a serous discharge (usually settles within two weeks but may persist for several weeks).

Reference:

• (1) Park DH, Singh D. The management of ingrowing toenails. BMJ. 2012;344:e2089
• (2) Doctor (April 26th 2005):21.