Paronychia and Ingrown Toenail

Essentials

• Acute paronychia usually responds well to simple drainage of the abscess without the need for systemic antimicrobials.
• Chronic paronychia is encountered mainly in people whose hands are repeatedly exposed to water.
• An ingrown toenail can be treated with conservative methods in mild cases. In more severe cases, partial nail avulsion is often required.

Aetiology

• Acute paronychia
  • May manifest itself as a painful abscess at the nail fold, or it may become chronic when the cuticle disappears and the entire nail fold becomes erythematous with or without flaking skin.
  • An acute infection starts from a small cut (e.g. nail biting or a manicure procedure) or an ingrown edge of a nail.
  • The most common causative agent is Staphylococcus aureus.
• Chronic paronychia (picture 1)
  • The aetiology is multifactorial and cannot be explained by infection alone.
  • It may halt the growth of the nail and the nail plate may become partially detached (pictures 2 3).
  • Particularly encountered in people involved in wet working conditions. A swab collected from under the nail fold may grow Candida albicans with simultaneous bacterial growth, including S. aureus, pseudomonas or E. coli, the clinical significance of which remains controversial.

Treatment

Ingrown toenail Surgical Treatments for Ingrowing Toenails

• Ingrown toenail is often caused by incorrect nail-cutting techniques, trauma, nail tearing or tight shoes.
• An ingrown toenail damages the lateral nail fold which results in pain, chronic inflammation and the formation of granulation tissue, which may sometimes be fairly extensive.
• Advice by a foot health practitioner regarding the correct nail cutting technique and any conservative treatments are beneficial in the prevention of ingrown toenails.
• In mild and distal cases, a foot health nurse's procedures are often sufficient: nail edge elevation, gutter treatment, orthonyxia (Podofix^® , nail brace etc.).
• It is also important to minimize irritating factors, e.g. having spacious footwear, correct cutting technique and regular care of nails and nail wall skin.
• In more severe cases, partial avulsion of the nail and phenolization have been used as treatment.
  • This approach is more effective and less traumatic than surgical wedge resection.
• The chronic symptoms of an ingrown toenail will not resolve with antimicrobials, and elevation or removal of the nail margin is warranted.
• After treatment of an ingrown nail (e.g. nail margin removal), the granulation tissue usually disappears spontaneously within 1-2 months. As necessary, granulation tissue can be removed superficially with a knife or a skin curette in association with nail margin removal (usually done under nerve block).

Partial nail avulsion with matrix phenolisation

• The procedure (video Lateral Edge Resection and Phenolization for Ingrowing Toenail) may be performed during an acute infection and a course of antimicrobials, or during a calm phase without an antimicrobial cover.
• Provide nerve block anaesthesia to the toe. Lidocaine without or with adrenaline is usually used as the anaesthetic.
• Apply a ring tourniquet to the toe.
• Cut a 3-5 mm section of the affected nail border with surgical scissors. Extend the cut to under the proximal nail fold. The detached nail section is lifted off complete with the germinal matrix using, for example, artery forceps. Attempt to remove the entire matrix in one piece.
• Dry the area and insert a cotton swab (e.g. a metal shafted pin used for the cleaning of the outer ear canal) soaked with 80% phenol into the nail groove created. Repeat the application 2-3 times so that the total application time is at least one minute. Remove excessive phenol by injecting physiological saline into the wound with a syringe.
• Remove the ring tourniquet. Apply a paraffin dressing over the wound and cover with gauze dressings. Keep the dressings in place with an elastic bandage.
• Instruct the patient to start bathing the toe on the next day for 10-15 minutes twice a day, for as long as discharge persists.
• An antimicrobial cream is applied after bathing.