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ingrowing toenail

Ingrowing toenail (Onychocryptosis)

An ingrown toenail is a very common, painful condition of the toe that occurs when the sides or corner of the toenail dig  into the skin at the end or side of the toe. It involves inflammation of the nail, which is accompanied by pain, local edema, redness of the skin, and quite often drainage of pus or serous fluid.

In most cases it leads to the destruction of the area under the nail and to a permanent nail deformity. In vulnerable populations, such as diabetics, this infection may lead to osteomyelitis, and consequently, to toe amputation. The condition mostly affects the outer edge of the big toe, although the nail on both sides of the toe, or nail on any toe can become ingrown.

  1. Improper trimming of toenails (very short), especially on the corners can cause the nail edge or corner to dig into the skin. This is maybe the most common cause for an ingrown nail.
  2. Congenital causes (curved nails)
  3. Ill fitting shoes, such as tight shoes, high heals and pointed-toe shoes cause the toes to be compressed together so that the nail curls into the skin and cannot grow normally
  4. Injury near the nail. Usually caused by ill-fitting shoes
  5. Conditions of the big toe

In general, ingrown toenails are especially common in teenagers and young adults due to rapid development that is not accompanied with the use of suitable shoes (tend to wear outgrown shoes). The condition also often affects soldiers, because of the constant strain they put on their feet, the lack of topical hygiene and their ill-fitting shoes (army boots).

Ingrown toenails can be classified into three stages according to severity. In stage I there is local edema, erythema (redness) and pain which is usually mild. In stage II the pain severity increases and there is discharge of serous fluid or pus. In stage III, lateral nail-fold hypertrophy (overgrowth of skin tissue around the affected toe) is observed, accompanied with the presence of intense inflammation.

The applied treatment depends on the stage of the condition. Initially is conservative, and includes the use of antibiotics and topical care with antiseptics. In particular:

  1. Frequent foot baths (34 times a day) with antiseptic soap and water.
  2. Wearing comfortable shoes or sandals.
  3. Antibiotic treatment that covers Gram-positive bacteria. Broader-spectrum antibiotics must be administered in diabetics and immunocompromised patients.
  4. Analgesics and anti-inflammatory medications.
  5. If there is no improvement after a few days, then a Surgeon must re-evaluate the condition.

When conservative treatment is not effective, the problem is recurrent or the surgeon diagnoses the patient with stage 2 or 3 symptoms, then surgery is the only and best treatment. Usually, the conservative treatment significantly helps local infection’s control, but doesn’t actually solve the problem. It only relieves its symptoms.

Surgery either involves resection of the affected nail section reaching to the nail matrix, or the excision of the entire nail in order to provide a definite solution for the patient. The surgical treatment of ingrown toenail, called nail plastic surgery or onychectomy, if done properly, may lead to a definite cure of the condition.

The procedure is performed under local anesthesia, with minimum postoperative pain, and the patient may walk directly after the treatment and return to his/her daily activities. The toenail heals completely within three weeks, and with the proper surgical technique, recurrences are extremely rare.

In conclusion, the ingrown nail is a very common condition of the toenail, which, if not properly treated, will cause problems to the patient’s daily life. Especially for diabetic patients, the infection may spread to the surrounding tissues, including the bone (osteomyelitis), and lead to more drastic surgeries and to hospitalization for intravenous antibiotic treatment. For all those reasons, patients should consult a doctor in the early stages of the infection in order to receive a combination of conservative and surgical treatment, and solve the problem permanently, minimizing the risk of ingrown nail recurrence.


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