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What is the best way to treat ingrowing nails?
Among foot and ankle problems I see on daily bases, ingrowing nails definitely takes top 5.
Ingrowing nails are very common in all age and sport groups. They can occur because of changes to the nail plate itself like thickening, widening, or excessive thinning and splitting. Injury or enlargement of nail folds can force the skin around the nail onto the nail plate thus impaling it and causing micro cuts in the skin around the nail. Another reason is excessive foot sweating which leads to fragile skin around the nail and therefore makes it easier for the nail plate to cut into the skin.
Sports or activities that involve frequent blunt trauma to the nail from the outside of inside of the shoe frequently result in ingrowing nails. Certain athletes such as soccer players and ultra-marathon runners are more prone to nail injuries overall and ingrowing nails in particular. In fact, I have had several ultra-marathon runners that came in requesting that all of their toenails are removed. This is because their nails regularly become partly detached and ingrown with frequent associated bleeding.
Left unaddressed, an ingrown nail will lead to swelling, redness, drainage, pain and ultimately infection!
While treating the nails without a procedure is possible, it is time consuming and unpredictable in terms of consistently achieving a positive outcome. Thus, most foot surgeons tend to recommend surgical resection of nail fold or ingrowing aspect of the nail with partial “burning” of nail root to treat the ingrowing nail and also prevent the nail from re-ingrowing!
Non surgical approaches
Non surgical treatment of ingrowing nails includes soaking the foot in salty warm water to promote nail fold swelling reduction, taping the nail fold to pull it away from the nail, placing cotton and other devices underneath the edges of the nail to pull it away from the nail fold. Even though these treatments may work, they require a very long period, high degree of persistence, frequent reapplication, and require high degree of adherence to technique. Repeat occurrence rate is high.
Taping: this involves attaching a strip of tape to the nail fold over ingrowing nail in such a way as to pull the nail fold away. The tape should be applied in an oblique fashion as to create downward and backward pull on the fold. Making tape stick is difficult partly because of foot washing and partly because of foot sweating. Using materials like Kinesio tape that have high adhesive potential and can be showered with will drastically improve success rate.
Packing: a small ball of cotton is placed underneath the distal ingrowing corner of the nail and the skin. If this is done in cases of nail ingrowing for more than a day, significant pain may be associated with this procedure. However, this maneuver physically pulls the nail plate away from the skin fold with resulting improvement in pain. This procedure must be done daily and for a fairly long period of time to achieve resolution.
Dental Floss: Instead of cotton, dental floss can be used just like cotton ball packing. The procedure and protocol are the same and require daily changes of packing.
Nail braces: various devices exist that go on top of the nail or get placed underneath the edges of the nail to straighten out the nail plate. These devices are more helpful for pincer type/dome shaped nails as opposed to straight nails growing in or enlarged/injured nail folds pressing into the nail plate.
One of the main reasons for ingrowing corners of the nail is inappropriate nail cutting technique. When the nails are cut too short or torn, the distal skin at edge of the nail rolls and becomes thick, in fact it tends to be taller than the nail plate itself. This prevents the nail from growing forward as a whole or in the corner. Frequently, a nail spicule is left in the corner with this incorrect cutting technique with then grows into the rolled distal nail fold. The therapy includes narrowing of the nail and “eliminating” the nail root on the ingrowing part of the nail.
Another reason for ingrowing nail is changes that actually occur UNDER the nail plate resulting in the condition called PINCER nail or a dome shaped nail.
This condition occurs when the bone underneath the nail goes through changes. These changes can be due to trauma to the bone (something heavy falling on the toe, stepping on the toe, running over the toe, toe hitting the object repeatedly like in soccer) or because of arthritic changes in the big toe joint resulting in widening of the joint.
This results in the bone growing in the upward direction resulting in dome shaped nail with callus forming under the nail. When x ray is taken, one can frequently see a bone spur growing underneath the nail. Treatment includes narrowing of nail plate or surgical resection of the bone spur.
So what will happen if you leave your ingrowing toenail untreated?
The answer depends on many things but mostly has to do what other medical conditions affecting the body.
One of the worst outcomes that can occur is a deep-seated infection that results from nail plate cutting into the skin of nail fold. This brings bacterial and fungus that naturally lives on the skin through the wound and into the deep tissue of the toe. If the infection is brought through soft tissue only, skin and related structure infection can result like abscess (collection of pus) or cellulitis (skin infection where bacterial starts traveling up the toe). If this goes untreated, the bacterial may progress into circulation and infect the rest of the body which may result in bacteremia (bacteria in the blood), sepsis (whole body response by immune system to infection) and even death. If the infection progresses to bone, one may end up with infection of the bone called osteomyelitis. This can be treated with antibiotics in early stages but can also require toe amputation in later stages.
Of course, untreated ingrown toenail will continue to create pain and will lead to inability to wear tight fitting shoes and socks.
In patients with compromised immune system like diabetics, those on dialysis or those undergoing cancer treatment, infection can progress quicker than in healthy population as body does not mount an immune response to bacteria. In addition, those people who have foot numbness may not appreciate the fact that they have an ingrown toenail and may not realize that they have an infection ravaging their toe until it is too late.
Frequently, patient’s with poor sensation in their feet notice infection because they see blood on their socks or start noticing a foul odor coming from their feet. Unfortunately, it is usually too late to save the toe by then and amputation is required to save at least their foot. Poor sensation can develop for various reasons some of which include uncontrolled diabetes, vitamin B12 and folate deficiency, exposure to agent orange, injury to nerves in lower back (traumatic or arthritic, viral infections, alcohol abuse, nerve injury in the legs, tumors around nerves, poor circulation, immune system disorders, fibromyalgia, strokes, and multiple sclerosis…just to name a few. Thus, it is essential that this condition is evaluated by a doctor to start early and appropriate treatment.
What about treating ingrowing toenails in babies and toddlers?
In this age group, ingrowing toenails tend to resolve on their own after 1-2 months. Treatment includes soaking the involved foot in warm soapy salty water and application of antibiotic ointment. If condition does not resolve or infection develops, removal of the nail may be required.
So what about surgical approach?
Either complete or partial toenail removal can be undertaken. I strongly recommend against removing of the whole toenail as this is a traumatic process and make result in mechanical damage of the nail root. This damage may result in a permanently deformed toenail. Partial toenail removal from the side that is ingrowing is almost always preferred. The only reason to remove the whole nail is if you already have a narrow nail plate or if the nail is not only ingrowing but also thick and infected with fungus. Given the nail growth a fresh start may result in a better nail appearance.
Removal of the nail is painful, so a local anesthetic is usually used. It is important to share with your doctor if you are allergic to local anesthetics and to what anesthetics specifically, as your doctor may have various alternatives that can be used.
Once your toe is numb, the numbness will persist for 4-6 hours depending on the anesthetic agent used. There are 4 nerves total located in each corner of the toe, so each one of those nerves must be anesthetized to achieve for a totally pain free toenail removal.
When the painful toenail portion is removed, you have 2 options. You may choose to let the nail grow out and observe it carefully for any evidence of ingrowing. Alternatively, you can take a proactive approach and choose to have the ingrowing nail permanently removed. If the second option is chosen, your doctor usually has several options to choose from. These include surgically cutting the nail root out in the area of the nail that tends to ingrow. An alternative is to apply a cauterizing agent thereby chemically destroying a portion of the nail root of the ingrowing nail. Phenol is the most commonly used chemical agent used for this purpose.
Phenol has multiple properties that make it extremely helpful for the doctor and the patient. It has a cauterizing effect which destroys nail root. Phenol produces an anesthetic effect which decreases patient’s pain. It also assists with slowing down bleeding by cauterizing blood vessels in the procedure area. Lastly, it has antifungal, antibacterial and antiviral properties! Other chemical agents are available as well but are not used as commonly. These include trichloroacetic acid and sodium hydroxide. Some believe that using these agents does not create as much post procedure drainage associated with the chemical burn created.
Drainage of clear fluid at procedure site may last for several weeks when phenol is used. This is normal and expected. In most cases, post procedural pain can be treated with same over the counter medications one would use to treat a headache. Most pain is usually gone by second or third day!
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Until next time…..happy walking!
Author bio:
My name is Dr. Marat Kazak. I have been working as a professional Podiatrist serving Northern California community since 2014. My extensive medical and surgical knowledge combined with an ongoing curiosity to learn about the latest trends define my success in the field of foot, ankle and leg medical and surgical care.
The goal of this website is to give you the tools to better care for yourself, to dispel medical myths, and to empower you with information to save time and money! If you are looking for an answer on foot and ankle pain, this is the place to find it. If you do not see your topic of interest covered, please send me a message and I will do my best to discuss it thoroughly in my next upcoming post.
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