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Basics ⬇

Author: Rodney S.Gonzalez, MD, FAAFP

Description

  • Onychocryptosis is commonly called ingrown toenail and most commonly affects the great toe.
  • Puncturing of the periungual skin by the nail plate; this leads to a foreign body (the nail plate), inflammatory, and (possibly) infectious processes (1).
  • Alteration in the proper fit of the nail plate into the lateral or medial nail groove
  • Improper fit leads to callous formation, edema, and perforation in the nail groove as a result of the rubbing of the nail plate against the nail groove.
  • Three stages (2):
    • Stage 1 (mild): erythema, slight edema, and pain when pressure is applied to the lateral nail groove
    • Stage 2 (moderate): increased stage 1 symptoms, drainage, and infection
    • Stage 3 (severe): worsening stage 1 symptoms, presence of granulation tissue, and lateral wall hypertrophy
  • Recurrence is not uncommon.
  • Synonym(s): unguis incarnatus; in-fleshed toenail; embedded toenail

Epidemiology

  • Most commonly affects the great toe
  • Lateral nail edge more common than medial nail edge
  • 26% of pathologic nail conditions
  • Most cases occur in males in their 2nd and 3rd decades.
  • Predominant gender: male > female (2:1 <30 yr of age, 1:1 >30 yr of age)

Etiology and Pathophysiology

  • Nail spicules form on the medial or lateral nail plate owing to trauma, disease processes, or improper hygiene.
  • Nail plate punctures the periungual skin, causing a foreign-body and inflammatory reaction.
  • Biologic agents (e.g., bacteria and fungi) may cause an infection of the periungual skin.

Risk-Factors

  • Shoes with tight-fitting toe box
  • Improperly fitting cleats
  • Poor stance and gait
  • Improper nail-trimming techniques (including tearing of nails)
  • Senior athletes
  • Onychomycosis
  • Diabetes
  • Hyperhidrosis
  • Obesity
  • Subungual neoplasms
  • Arthritis
  • Immune deficiency
  • Trauma, acute and repetitive
  • Skeletal abnormalities
  • Family history of incurvated nails
  • Congenital and acquired nail disorders

General Prevention

  • Properly fitting footwear
  • Proper nail trimming

Commonly Associated Conditions

Diagnosis ⬆ ⬇

History

  • Ask about tight-fitting shoes: Small toe boxes predispose to onychocryptosis.
  • Signs of infection: erythema, edema, and pain
  • Ask about recurrence and previous treatment: may affect treatment choice
  • History of immune deficiency or abnormal wound healing: increased chance for severe infection and possibly requires the use of antibiotics

Physical Exam

  • Signs and symptoms:
    • Pain, swelling, and limitation of activities
    • Cardinal signs of inflammation (redness, warmth, and drainage)
    • Incurvated nail margin
  • Physical examination:
    • Tenderness, erythema, edema, drainage
    • Inspect for foreign bodies.
    • Cardinal signs of ascending infection (redness traveling up the foot); this is more common in individuals with poor circulation or diabetes.
    • Presence of excess medial or lateral wall tissue

Differential Diagnosis

  • Osteomyelitis
  • Cellulitis
  • Felon
  • Paronychia
  • Foreign body
  • Tumor

Diagnostic Tests & Interpretation

  • Labs usually not necessary
  • Consider complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) ± blood cultures if there is concern for a more severe infection (e.g., osteomyelitis).
  • Plain films and/or bone scan may be required for a severely infected toe if osteomyelitis is suspected.

Treatment ⬆ ⬇

  • Long-term treatment
  • Acute treatment
  • Analgesia (1)[C]:
    • Depends on planned treatment option and patient discomfort level
    • Recommend performing local anesthesia or a digital block with 1–2% lidocaine without epinephrine before manipulation.
    • Ibuprofen or acetaminophen for postoperative pain control
  • Immobilization (1)[C]:
    • Patients may be full weight-bearing after non-surgical treatment.
    • Partial weight-bearing for 24 to 48 hr after surgery may be needed, but generally, weight-bearing is well tolerated.
  • Nonsurgical treatment (1,2)[C]:
    • There are no trials that compare the cost-benefit of nonsurgical versus surgical treatment options.
    • Patients should be instructed in maintenance of proper foot hygiene, avoidance of shoes with a tight-fitting toe box, soaking the feet, properly trimming nails (cutting the nail straight across), and avoidance of repetitive trauma.
    • Conservative treatment options (1,2)[C]:
      • Foot soaking: 10 to 20 min in warm, soapy water, followed by application of topical antibiotic ointment for a few days until resolution
      • Cotton wisps: Place cotton under the ingrown nail edge (also may be done with dental floss).
      • Gutter splint: using plastic tubing (e.g., intravenous [IV] infusion tubing) with a vertical slit and placing this over the ingrown nail edge
      • Small metal brace placement (such as KD device) around both edges of nail to relieve nail pressure (3)[C]
      • Cure rates can be as high as 75% with good patient compliance for stage 1 lesions.
      • If infection is suspected, it is important to remove the source of the infection. Antibiotics are usually not required when doing surgical treatment; when using antibiotics, they should be directed against gram-positive bacteria (e.g., Staphylococcus aureus and Streptococcus spp.).

Surgery/Other Procedures

  • Surgery may be recommended for recurrent stage 1 lesions as below for stage 2 lesions:
    • Stage 2: Remove with a wedge excision the distal outer nail edge without matrixectomy.
    • Stage 2 or 3: partial removal of the medial or lateral nail with matricectomy (medial/lateral nail avulsion) ± electrosurgical or phenol cauterization
    • Stage 3: in addition to the preceding, ablation of medial or lateral wall tissue to promote normalization of the medial/lateral nail fold
  • Major contraindications include disorders causing digital ischemia (e.g., diabetes, peripheral vascular disease, and collagen diseases).
  • Studies show that antibiotics before or after surgery do not affect healing time and should be withheld in most cases. One study showed increased risk of infection after nail matrixectomies compared to clean foot and ankle surgery. They suggest providers should consider this a clean-contaminated surgery and may provide indication for antibiotic prophylaxis (4)[C].
  • Partial nail removal with phenolization decreases the risk of recurrence; however, there may be a slight increase in postoperative infections (1,5)[C].
  • Matricectomy with electrocautery and radiofrequency and carbon dioxide laser is also effective; the high cost of these procedures may be prohibitive, however (2)[C].

Ongoing Care ⬆ ⬇

Follow-up Recommendations

Immunocompromised individuals with a severe infection may require hospitalization for administration of IV antibiotics.

Patient Education

Complications

  • Osteomyelitis
  • Narrowing of nail (when matrix ablation performed)
  • Recurrence

References ⬆ ⬇

  1. Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician. 2009;79(4):303–308.
  2. Park DH, Singh D. The management of ingrowing toenails. BMJ. 2012;344:e2089.
  3. Arik HO, Arican M, Gunes V, et al. Treatment of ingrown toenail with a shape memory alloy device. J Am Podiatr Med Assoc. 2016;106(4):252–256.
  4. Rusmir A, Salerno A. Postoperative infection after excisional toenail matrixectomy: a retrospective clinical audit. J Am Podiatr Med Assoc. 2011;101(4):316–322.
  5. DeBrule MB. Operative treatment of ingrown toenail by nail fold resection without matricectomy. J Am Podiatr Med Assoc. 2015;105(4):295–301.

Clinical Pearls ⬆

  • Antibiotics have not been shown to change the healing from ingrown toenails when using surgical treatment options.
  • Impact activities should be avoided until the patient is pain free and clear of infection.
  • The frequencies of symptomatic nail regrowth following distal nail wedge resection is 70%, nail avulsion in 50–80%, phenol cauterization is 4–25%, and electrosurgical cauterization is <5%.