WASHINGTON Proper early management of ingrown toenails may help to decrease the risk of recurrence whether or not surgery is necessary, Dr. C. Ralph Daniel III said at the annual meeting of the American Academy of Dermatology.
"An ingrown nail is primarily acting as a foreign-body reaction. That rigid spicule penetrates soft surrounding tissue" and produces swelling, granulation tissue, and sometimes a secondary infection, said Dr. Daniel of the departments of dermatology at the University of Mississippi, Jackson, and the University of Alabama, Birmingham.
For the early management of stage I ingrown toenails in which some granulation tissue but no infection is present, Dr. Daniel has trained his nurse to push wisps of cotton gently under the involved ingrowing nail by using a 2-mm nail elevator or a 1− to 2-mm curette.
He also uses a technique for early-stage ingrown toenails in which dental floss is inserted under the ingrown nail corner without anesthesia and is kept there to separate the nail edge from adjacent soft tissue (J. Am. Acad. Dermatol. 2004;50:93940).
Dr. Daniel formerly was on the board of directors for Doak Dermatologics, a subsidiary of Bradley Pharmaceuticals Inc., which manufactures urea-based products for nail care. He holds stock options and has served as a speaker, consultant, and investigator for the company.
A procedure that uses an acrylic-affixed gutter splint has been reported to be successful for avoiding surgery, Dr. Daniel said. A plastic gutter tube is set under the ingrown part of the nail and acrylic is sculpted and allowed to polymerize around the ingrown part of the nail and hold the gutter tube in place. The tubes are removed once the inflammation has subsided and the nail has grown appropriately (Int. J. Dermatol. 2004;43:75965).
Surgery should not be performed on a patient with an ingrown toenail in a more advanced stagemore granulation tissue, significant pain, possible infectionuntil the level of inflammation has been reduced with salt soaks in warm water (as opposed to cold, because of the possibility of infection) and topical application of steroids three times a day for about a week, Dr. Daniel said. He doesn't use urea very often in these cases because it does not seem to work as well as it does for early-stage ingrown toenails.
Before surgery, leave plenty of time for anesthesia using a digital block or a distal approach to take effect. Premedication with NSAIDs, codeine, or dextropropoxyphene also may be appropriate, he said. Dr. Daniel uses a timer and does not keep a tourniquet on for more than 15 minutes; most procedures do not take longer than that (some surgeons do not use tourniquets).
To cut away the offending section of nail, an English anvil nail splitter is inserted under the nail plate and the cut is made all the way to the proximal nail fold. The hypertrophic, granulated tissue should be cut away as well. Many ingrown toenails are recurrent, so Dr. Daniel performs a chemical matricectomy in nearly all patients after making sure that the surgical field is dry and bloodless.
The proximal nail fold can be flared back to expose more of the proximal matrix if necessary. He inserts a Calgiswab coated with 88% phenol or 10% sodium hydroxide and applies the chemical for 30 seconds to the portion of the nail matrix that needs to be destroyed.
An Ellman electrode can be used to electrodesiccate the matrix, followed by curettage. The CO2 laser also has been used to perform a partial matricectomy after removal of the nail spicule and staining of the nail matrix with methylene blue (Dermatol. Surg. 2005;31:3025).
An ingrown toenail is shown. ©Jeff Horn/Fotolia