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BASICS

  • Description: Nail plate margin penetrates lateral nail fold → irritation, inflammation, possible bacterial/fungal infection.
  • Stages:
  • Stage 1: Inflammation – erythema, edema, tenderness.
  • Stage 2: Abscess – increased pain, purulent/serous drainage.
  • Stage 3: Granulation – chronic inflammation with granulation tissue and nail fold hypertrophy.
  • Synonyms: Onychocryptosis, unguis incarnatus.

EPIDEMIOLOGY

  • Great toenail most commonly affected.
  • Lateral edge > medial edge.
  • Most common in males aged 14-25 years.
  • More frequent in elderly females than elderly males.
  • Prevalence: ~2.5% general population; 5% in >65 years; male:female ratio 2:1.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Nail plate invades nail fold → foreign body inflammatory reaction.
  • Secondary bacterial/fungal infection possible → abscess.
  • Chronic inflammation → granulation tissue and hypertrophy of nail fold.

RISK FACTORS

  • Genetic predisposition.
  • Increased nail fold width, decreased nail thickness.
  • Medial rotation of toe.
  • Thickened/distorted nails, fungal infections.
  • Improper nail trimming.
  • Poorly fitting shoes.
  • Trauma to nail or fold.
  • Conditions causing pedal edema (thyroid disease, diabetes, obesity, heart/renal failure).

PREVENTION

  • Properly fitting footwear.
  • Correct nail trimming (straight across, not too short, avoid rounding corners).

DIAGNOSIS

History

  • Pain, redness, swelling along one or both sides of nail.
  • Possible drainage (serous or purulent).

Physical Exam

  • Tenderness, erythema, edema of nail fold.
  • Drainage if abscess present.
  • Granulation tissue and lateral nail fold hypertrophy in chronic stages.

Differential Diagnosis

  • Cellulitis
  • Felon (pulp abscess)
  • Onychogryphosis
  • Onycholysis
  • Onychomycosis
  • Osteomyelitis
  • Paronychia
  • Subungual exostosis or osteochondroma

Diagnostic Tests

  • Usually none.
  • X-ray, MRI, or bone scan if osteomyelitis suspected.
  • X-ray if bony tumors suspected.

TREATMENT

General Measures

  • Mild (stage 1) often responds to conservative care:
  • Warm soapy water or Epsom salt soaks (10-20 min, 3x daily).
  • Gently lift ingrown nail edge with cotton or dental floss.
  • Use tape to pull lateral nail fold away from nail plate.

Medications

  • NSAIDs for pain.
  • Topical antibiotics after soaking.
  • Oral/topical antibiotics not useful adjuncts to surgery.

Surgery

  • Partial nail avulsion with phenol matrix ablation is most common and effective surgical treatment.
  • Procedure:
  • Digital block anesthesia.
  • Tourniquet for hemostasis (caution in diabetes/PVD).
  • Longitudinal nail incision and removal of ingrown portion.
  • Phenol application (80-88%) to nail matrix, neutralized by alcohol.
  • Alternative matrix ablation: sodium hydroxide, cryotherapy, electrocautery, CO2 laser.
  • Flexible gutter splint for stages 2-3 as nonsurgical option.
  • Bilateral partial matricectomy for severe or recurrent cases.

ONGOING CARE

  • Post-op dressing with antibiotic ointment or petroleum jelly.
  • Elevate foot 12-24 hours post-op.
  • NSAIDs for discomfort.
  • Daily dressing changes and cleaning for 1-2 weeks.
  • Nail regrowth may take 6-12 months without matrix ablation.
  • Follow-up every 7-10 days until improvement.

PATIENT EDUCATION

  • Trim nails straight, not rounded or too short.
  • Wear comfortable, well-fitting shoes.

COMPLICATIONS

  • Post-surgical cellulitis (uncommon).
  • Nail bed or matrix damage → nail deformity.
  • Distal toe ischemia (rare, prolonged tourniquet).
  • Osteomyelitis (rare).
  • Persistent drainage.
  • Recurrence: 40-80% with avulsion alone; 0.6-14% with matrix ablation; 6-13% with gutter splint.

REFERENCES

  1. Mayeaux EJ Jr, Carter C, Murphy TE. Ingrown toenail management. Am Fam Physician. 2019;100(3):158-164.
  2. Thakur V, Vinay K, Haneke E. Onychocryptosis—decrypting the controversies. Int J Dermatol. 2020;59(6):656-669.
  3. Eekhof JAH, Van Wijk B, Knuistingh Neven A, et al. Interventions for ingrowing toenails. Cochrane Database Syst Rev. 2012;(4):CD001541.
  4. Park DH, Singh D. The management of ingrowing toenails. BMJ. 2012;344:e2089.
  5. Nazari S. A simple and practical method in treatment of ingrown nails: splinting by flexible tube. J Eur Acad Dermatol Venereol. 2006;20(10):1302-1306.

CLINICAL PEARLS

  • Nonsurgical care effective in stage 1 and mild stage 2 ingrown toenails.
  • Partial nail avulsion with phenol matrix ablation is the most common surgical intervention.
  • Proper nail trimming and shoe fitting prevent recurrence.
  • Antibiotics are not indicated adjuncts to surgery.