Definition of Ingrowing Toe Nail

Known to podiatrists as onychocryptosis, ingrown toe nails are a common, painful condition that occur when skin on one or both sides of a nail grows over the edges of the nail, or when the nail itself grows into the skin. This condition is usually very painful and can be associated with infection of the toe. Some ingrown toenails are chronic, with repeated episodes of pain and infection. Irritation, redness, an uncomfortable sensation of warmth, as well as swelling can result from an ingrown toenail.

Cause of Ingrowing Toe Nail

Ingrown toenails develop for many reasons. In some cases the condition is congenital, such as toenails that simply are too large. People whose toes curl, either congenitally or from diseases like arthritis, are prone to ingrown toenails. Often trauma, like stubbing a toe or having a toe stepped on, can cause a piece of the nail to be jammed into the skin. Repeated trauma,such as the pounding to which runners typically subject their feet, also can cause ingrown nails.

The most common cause is cutting your toenails incorrectly, causing them to re-grow into the skin. Tight hosiery or shoes with narrow toe boxes only make matters worse. If the skin is red, painful or swollen on the sides of the nail, an infection may be present. This occurs because the ingrown nail is often in a warm, moist and bacteria-rich environment. When the nail penetrates the skin, it provides a convenient entry for germs that can cause infection. Untreated, the nail can go under the skin, causing a more severe infection. In either case, the infection needs to be cured with sterile instruments and antibiotics.

Treatment and Prevention of Ingrowing Toe Nail

Ingrown toenails should be treated as soon as they are recognized. In many cases, people with uninfected ingrown toenails can obtain relief with the following simple regimen:

• Soak the feet in warm salt water
• Dry them thoroughly with a clean towel
• Apply a mild antiseptic solution to the area
• Bandage the toe

If excessive inflammation, swelling, pain or discharge is present, the toenail probably is infected and should be treated by a Podiatrist; who can trim or remove the infected nail with a minor in-office surgical procedure. He or she can remove the offending portion of the nail or overgrown skin with a scalpel and treat the infection. Unless, the problem is congenital, the best way to prevent ingrown toenails is to protect the feet from trauma and wear shoes with adequate room for the toes.

Cutting toe nails properly goes a long way toward the prevention of ingrown toenails. Using a safety nail clipper, cut the nails straight across, so that the nail corner is visible. If you cut the nail too short, you are inviting the nail corner to grow into the skin. It is the natural tendency, when the edge of the nail starts to grow in, to cut down at an angle at the nail edge, to relieve the pain. This does relieve the pain temporarily, but it also can start a downward spiral, training the nail to become more and more ingrown.

Here at Leyton Foot Clinic, we can treat upto 80% of all ingrowing toenails with conservative treatment, by just using either a scalpel or special fine pointed nail cutters. the remaining 20% of cases, need minor surgical intervention.

How will surgery correct the deformity?

Whilst removing the nail will resolve the current problem, the nail will grow back and it is likely that you will be left with the same problem. In order to prevent the nail growing, the troublesome section of nail is removed and a strong chemical, phenol, is applied to prevent the nail from re-growing. In the vast majority of patients we only need to remove a small section at one or both sides of the nail (partial nail avulsion). This leaves you with a narrower nail but without the troublesome section. In some instances, the whole nail needs removing (total nail avulsion). In this case, there will be no further nail growth.

If an ingrown toenail has been present for some time, there is often a build up of excess tissue that bleeds easily and looks red. This is known as hypergranulation tissue and is an over reaction to the irritation and / or infection. This will be removed during the operation.

What will happen at the operation?

The operation will be performed under local anaesthetic, so you are awake and can eat normally up until the time of your operation. The injection is given at the base of the affected toes and is generally more comfortable than a dental injection. The operation will last for approximately 10-15 minutes per toe but you may be at the clinic for much longer to allow sufficient preparation and post operative monitoring. A large dressing will be placed on your toes. so remember to bring along a sandal. You should avoid wearing tight clothing.

What are the advantages of this operation?

• Less discomfort
• No episodes of infection
• Easier shoe choice
• Easier walking

Whilst it cannot be guaranteed that you will never have another problem with the toe or be completely pain free, it is highly likely that your toe will be much improved.

I have heard it is a very painful operation.

Advances in techniques, local anaesthetics and pain killers now mean that patients have a high level of success with much less pain. Generally speaking, there is very little discomfort the night of the operation or during the healing period, depending on the tightness of the shoes worn. It is rare that the level of pain is not controlled by normal headache tablets (e.g.Paracetamol); and keeping the foot elevated.

What are the complications?

Every effort is made to minimise the risk of complications and these are rare. However, some specific complications may occur, such as:

• Prolonged weeping
• Infection. This can occur during recovery although the operation is often performed due to an infected ingrown toenail, thus this is less likely once the nail has been removed
• A reaction to phenol (phenol flare) can occur but this is rare and will be dealt with if necessary (less than 1%)
• Re-growth of the nail. This occurs in approximately 5-8% of patients undergoing partial nail avulsion and 10% of those undergoing total nail avulsion. The re-growth is often less troublesome than the original problem but the procedure can be repeated if necessary.
• In rare cases a small section of nail can re-grow beneath he skin at the base of the nail (less than 0.5%). This can form a small cyst, which requires excision.

Although all these complications are possible they are infrequent. Please be sure to discuss any areas of concern with your podiatrist as well as specific complications related to the procedure you may undergo.

How long will it take me to recover?

• You should not drive following the operation. We advise you to arrange a lift or get a taxi after the operation.
• We generally advise you to rest the first night and take pain killers as necessary.
• We generally advise you to keep your foot elevated for the first 24 hours.

First week

• The application of the phenol to destroy the nail bed causes a chemical burn, which takes time to heal. you will be reviewed after every 2/3 days of the operation, and redressed accordingly.
• It is advisable to keep the foot dry and covered.
• You should be able to get about fairly well but may need to take care with your shoe choice and avoid excessive activity.

Between 2-6 weeks after surgery

• You will need to re-dress the toe and do salt water footbaths for 10 minutes on a daily basis, until the toe stops weeping. On average, this occurs between 2-6 weeks following the operation. Generally, this is sooner rather than later.
• You should be relatively active during this period.
• You will be seen as and when necessary, depending on the outcome of the toe.

Please note, if a complication arises, recovery may be delayed, but don’t worry we at Leyton Foot Clinic will continue to review and monitor the situation until the toe completely heals.