Surgical Management of Ingrowing Toenails

What Is an Ingrown Toenail?

The condition in which the toenail grows into the skin around it is an ingrowing toenail. It is also referred to as onychocryptosis. The skin may get damaged, resulting in pain and infection. It mostly affects the big toenails. The condition is most prevalent in young males and accounts for 20 percent of foot issues in primary care. Footwear, improper nail trimming, foot hygiene, genetic predisposition, repetitive trauma, etc., can contribute to the condition.

Conditions like thyroid issues, cardiac problems, diabetes, renal disorders, and obesity can lead to edema (swelling due to fluid accumulation) of the lower extremities, which increases the risk of developing ingrown toenails. During adolescence, the feet may perspire more, which can soften the nails and skin, and the nail splits that occur can pierce the lateral skin. The risk of developing ingrown toenails is higher in old age, possibly due to reduced nail care due to impaired vision and thickened nails.

Ingrown toes are classified as:

• Mild Cases- It presents with swelling and redness of the nail-fold region and pain with pressure.

• Moderate Cases- It presents with increased swelling, drainage, infection, and ulcers in the nail fold region.

• Severe Cases- It presents with granulation, chronic inflammation, and nail-fold hypertrophy (alteration of shape or partial loss of the nails).

What Are the Treatment Options?

Ingrown toenails, if untreated, progress, and the toes become more painful, affecting the individual’s functional ability.

Treatment is indicated in the following cases:

• Secondary infection.

• Pain.

• Recurrent paronychia (infection of the skin around the toenails)

• Onychogryphosis (a yellow-brown opaque thickening of the nail plate with increased curvature)

Non-surgical treatment options are preferred in cases of mild to moderate ingrown toenails. In moderate to severe cases of ingrown toenails, surgical treatment is indicated. Using topical or oral antibiotics before and after treatment does not improve the treatment outcome. Some studies suggest that surgical treatment options are better at preventing recurrence than non-surgical options.

What Are the Non-surgical Treatment Options?

Non-surgical treatment mainly aims at relieving the symptoms and preventing recurrence and progression. It is usually indicated in mild to moderate cases that do not show significant erythema, pain, or discharge. Conservative management is a cost-effective method. The treatment is continued until the nail grows beyond the lateral nail edge.

The conservative options include:

• Appropriate footwear with a wide-toe box.

• Soak the affected toe and foot in warm, soapy water for ten to twenty minutes. After this, apply a steroid cream over the affected area. Continue this several times a day for 2 to 14 days.

• Using tape to pull the nail fold away from the nail plate.

• Application of a gutter splint to ingrown nail edge after local anesthesia infiltration. A vinyl intravenous tubing is cut diagonally and placed over the ingrowing nail plate side. The splint is affixed with tape, sutures, or wound closure strips.

What Are the Surgical Treatment Options?

The main aim of surgical treatment is to eliminate the interaction between the nail plate and the nail fold to prevent trauma and local body reactions. Surgical management helps relieve the pressure of the nail plate on the fold.

Surgical treatment is contraindicated in the following cases:

• Allergy to anesthetic medications.

• Uncooperative patient.

• Bleeding disorders.

• Uncontrolled diabetes mellitus.

• Peripheral vascular disease.

• Pregnancy (phenol exposure is contraindicated).

Partial nail avulsion is the most common surgical procedure for treating localized ingrown toenails. The surgical techniques involve nail avulsion (complete toenail removal), Zadek’s procedure (complete toenail removal and cutting the tissue area from which the toenail grows), wedge excision (partial removal of the toenail in the region it grows into the skin), and nail bed ablation.

Partial Nail Avulsion Procedure:

• A duly informed consent is to be provided to the patient.

• The patient is supine with legs extended, feet hanging out of the table, or knees flexed and feet flat on the table.

• A digital nerve block is given.

• Apply povidone, iodine, or alcohol.

• A hemostat or septum elevator is used to push the cuticle of the nail plate.

• The lateral edge of the nail plate is gently lifted using a hemostat.

• The nail plate edge is held using a straight hemostat, and the nail plate edge is disarticulated from the nail bed.

• The lateral edge of the nail plate is cut using a nail splitter.

• After nail removal, the lateral sulcus is examined to ensure no nail pieces remain.

• A plain white petrolatum gauze is applied after surgery.

Nail Matrixectomy: Matrixectomy can be performed chemically, electrosurgical, surgically, or by radiofrequency ablation. In most cases, unilateral matrixectomy is beneficial, but over time, contralateral ingrown nail toes can occur. A bilateral partial matrixectomy helps maintain the nail plate's aesthetic and functional roles.

The different nail matrixectomy methods are:

• Phenol: This method directly applies 80 to 88 percent of the phenol solution to the nail matrix, sparing the nail bed. A thorough rinsing with isopropyl alcohol follows this. Phenol chemical ablation has a lower recurrence rate but is disfiguring. Because of its hemostatic and antiseptic effects, phenol ablation benefits patients with diabetes and those on anticoagulants.

• Sodium Hydroxide: In this method, 10 percent sodium hydroxide is applied to the lateral horn of the nail matrix using a cotton applicator tip, followed by rinsing with isopropyl alcohol.

• Electrosurgical: In this procedure, electrodes are placed over the lateral nail bed, and the electrode is slightly lifted, creating a small gap. The electrode is activated for about three to ten seconds. Prolonged electrode activation is avoided to prevent damage to deeper tissues.

What Are the Postoperative Instructions?

• The toe should be elevated and rested for 12 to 24 hours following surgery.

• Pain medications may be prescribed.

• The dressing should be changed every one to two days.

• If healing is improper even weeks after the procedure, debridement, oral antibiotics, and radiologic examination are needed.

What Are the Complications?

• Anesthesia complications.

• Bleeding.

• Allergic reactions to materials used.

• Unsightly scarring.

• Pain.

• Recurrence.

• Wound infection.

• Infection of the underlying bone.

Conclusion

Surgical management of ingrown toenails is indicated in cases where conservative options fail or in severe cases. The associated complications include surgical complications like bleeding, infection, anesthesia complications, wound complications, scarring, etc.