Chapter 184. Ingrown Toenail Management

An ingrown toenail (onychocryptosis) is a common affliction that can occur in any toe. It most commonly afflicts the great toe, occurring when the lateral edge of the nail plate penetrates the soft tissue of the lateral nail fold. There are three stages of ingrown toenails. Stage I includes erythema, slight edema, and pain when pressure is applied to the lateral nail fold. Stage II includes the stage I findings plus signs of infection and a purulent drainage. Stage III is a magnification of the two previous stages with the addition of granulation tissue formation and lateral nail fold hypertrophy. Most ingrown toenails can be definitively managed in the Emergency Department by the Emergency Physician.

The toenail usually does not grow into the soft tissue. Instead, the soft tissue overgrows and obliterates the nail sulcus in response to external pressure and irritation.1–5 The toenail itself is usually normal, although some older patients may have incurved nails. The causes of an ingrown toenail are multiple and include trimming the toenails too short, using sharp tools to clean the toenail gutters, wearing improperly fitted (too tight) shoes, rotated digits, and bony deformities. Improper toenail trimming can result in a small nail spike on the lateral aspect of the toenail (Figure 184-1). As the toenail continues to grow, the spike will irritate the soft tissue causing the end result of chronic inflammation and an infection.

Warm soaks, oral antistaphylococcal antibiotics, and shoes with an adequate toe box may be curative in mild cases (stages I and II). Elevate and maintain the nail edge above the soft tissues or trim the edge of the nail (Figure 184-2). More severe cases (stage III) require partial toenail removal. Have a lower threshold for toenail removal in diabetic patients to prevent a more severe infection from forming. Other indications for removal of an ingrown toenail include chronic or recurring ingrown toenails, failure of conservative therapy, fungal infections of the toenail, and severe pain.

The only relative contraindication to toenail removal is a decreased vascular supply to the toe. Trim the toenail edge if possible and minimize any injury to the adjacent soft tissues. These patients require an evaluation by a Podiatrist and a Vascular Surgeon to minimize future complications.

General Supplies

• Povidone iodine or chlorhexidine solution
• Sterile drapes
• Sterile gloves
• Curved hemostat
• Freer or another periosteal elevator
• Cotton
• Scissors or nail splitter
• Tourniquet or sterile Penrose drain
• Curette
• Topical antibacterial ointment
• 4 × 4 gauze squares
• Tape, 1 inch wide

Chemical Matrix Ablation

• Above listed general supplies
• Cotton-tipped applicators
• 89% phenol solution
• 70% isopropyl alcohol solution
• Silver nitrate matchsticks

Surgical Matrix Excision

• Above listed general supplies
• #15 scalpel blade on a handle
• Needle driver
• 5-0 nylon suture

Nail Matrix Cauterization

• Above listed general supplies
• Electrocautery unit, disposable

Explain the risks, benefits, complications, and aftercare of the procedure to the patient and/or their representative. Obtain an informed consent for the procedure. Place the patient supine on a gurney or procedure table. Flex the patient's hip and knee so that the plantar surface of their foot is flat against the gurney. An overhead light source is essential to provide appropriate illumination. Perform a digit block using aseptic technique. Refer to Chapter 126 regarding the details of digital anesthesia. While rare, an occasional nervous or uncooperative patient may require an intravenous anxiolytic or even procedural sedation prior to the digital anesthesia. The young child will require physical restraint with a sheet or commercial device (e.g., Papoose board) and procedural sedation. Apply povidone iodine or chlorhexidine solution over the involved toe and allow it to dry. Apply a sterile drape to delineate a sterile field.

Manage early ingrown toenails (stages I and II) with conservative therapy. Remove the medial or lateral one-quarter of the toenail along with the germinal matrix at the base of the toenail for stage III ingrown toenails. The entire nail may be removed if both sides are ingrown. It may be necessary to prevent any new nail growth in the area once the nail has been removed. Three options include chemical ablation of the matrix, surgical excision of the matrix, and electrocautery of the nail matrix. The treatment of the pediatric patient is no different than the adult patient.

Toenail Elevation and Trimming

Ingrown toenails in the first two stages can be trimmed or elevated to relieve the patient's symptoms (Figure 184-2). Trim the distal edge of the nail plate to remove the ingrown portion (Figure 184-2A). Remove the distal one-third to one-half of the nail plate. Smooth the nail plate edge so that it will grow out freely. Remove any debris along the lateral nail fold (paronychia) or nailbed.

An alternative is to elevate the edge of the nail plate (Figure 184-2B). Insert the jaws of a hemostat so that one is above and the other is below the ingrown nail edge. Clamp the jaws of the hemostat onto the nail plate. Slowly rotate the hemostat to elevate the edge of the nail plate above the adjacent soft tissues (Figure 184-2B). Insert a wad of cotton under the nail edge to maintain it above the adjacent soft tissues. Release the hemostat. Teach the patient and/or their representative this technique so that they can replace the cotton wad daily until the nail plate grows out and past the soft tissues. The main disadvantages of this technique are that the patient or their representative must elevate the nail edge and replace the cotton daily as well as maintain the nail plate elevation for 3 to 6 weeks. This can be quite a challenge, if it is even possible, in the young child.

Toenail Removal

Apply a tourniquet along the base of the afflicted toe (Figure 184-3A). The tourniquet may be a commercially available product for the digits or a Penrose drain. Refer to Chapter 104 for several examples of digital tourniquets. Separate the nail from the underlying nail bed. Grasp and stabilize the toe with the nondominant hand. If available, use a Freer periosteal elevator to lift the soft tissue off the lateral and proximal toenail. The elevator can also be used to separate the nail plate from the underlying nail bed, but this is optional. Insert one jaw of a curved hemostat under the distal toenail margin and along the medial or lateral side of the nail plate, depending upon which side is ingrown (Figure 184-3B). Advance the hemostat until the jaw is at the proximal corner of the involved side of the ingrown nail (Figure 184-3C). Grasp the nail by clamping the jaws of the curved hemostat on the toenail.

Dislodge the ingrown nail from the skin, the nail bed, and the nail matrix by rotating the hemostat away from the ingrown portion (Figure 184-3D). Continue to rotate the hemostat until the entire ingrown portion of the nail is separated from the skin, the nail bed, and the nail matrix. A large and complete portion of the underlying toenail will emerge from under the skin fold (Figure 184-3E). The nail plate might have broken and a significant piece may still be under the inflamed skin border if only a small amount of the nail is visible after rotating the hemostat. Expose this area and use the curved hemostat to remove any remaining nail plate.

Cut away the ingrown portion of the toenail, from distal to proximal, with a heavy scissors or nail splitter (Figure 184-3F). Make sure that the points of the scissors or nail splitter are facing upward to prevent injury to the nail bed. The granulation tissue overlying the nail bed must be removed to prevent another ingrown toenail (Figure 184-3G). Trim the granulation tissue using a #15 scalpel blade or a curette (Figure 184-3H). Remove the tourniquet and control any bleeding.

Some Emergency Physicians prefer to perform the above-described procedural steps in a slightly different order. Apply a tourniquet along the base of the afflicted toe. Grasp and stabilize the toe with the nondominant hand. If available, use a Freer periosteal elevator to lift the soft tissue off the lateral and proximal toenail. The elevator can also be used to separate the nail plate from the underlying nail bed, but this is optional. Cut away the ingrown portion of the toenail, from distal to proximal, with a heavy scissors or nail splitter. Make sure that the points of the scissors or nail splitter are facing upward to prevent injury to the nail bed. Insert one jaw of a curved hemostat under the distal toenail margin and along the medial or lateral side of the nail plate, depending upon which side is ingrown. Advance the hemostat until the jaw is at the proximal corner of the involved side of the ingrown nail. Grasp the nail by clamping the jaws of the curved hemostat on the toenail. Dislodge the ingrown nail from the skin, the nail bed, and the nail matrix by rotating the hemostat away from the ingrown portion. Continue to rotate the hemostat until the entire ingrown portion of the nail is separated from the skin, the nail bed, and the nail matrix. A large and complete portion of the underlying toenail will emerge from under the skin fold. The nail plate might have broken and a significant piece may still be under the inflamed skin border if only a small amount of the nail is visible after rotating the hemostat. Expose this area and use the curved hemostat to remove any remaining nail plate. Remove the granulation tissue overlying the nail bed to prevent another ingrown toenail using a #15 scalpel blade or a curette. Remove the tourniquet and control any bleeding.

Chemical Nail Matrix Ablation

Chemical ablation of the nail matrix with phenol has several advantages.6,7 The procedure is easy, quick, and simple to perform. No special equipment is required. The use of an incision or electrocautery, and their associated complications, is avoided.

Chemical ablation of the matrix with phenol is the author's preferred method. Remove any obvious remaining nail matrix and nail bed with a blunt instrument such as a curette. Completely dry the field of any blood and fluid. Dip a cotton-tipped applicator in a phenol solution. Avoid excessive saturation of the swab. Introduce the swab between the roof and the root matrix (i.e., under the eponychium) of the removed nail section (Figure 184-4). Rotate the cotton-tipped applicator slowly for 30 seconds (20 seconds for children) and then remove it. Repeat the phenol application two additional times using a fresh phenol-soaked cotton-tipped applicator. Do not allow the phenol to contact normal skin. Immediately wipe off any phenol that contacts the skin. The phenol will turn the tissue pale or gray. Dip a cotton-tipped applicator in isopropyl alcohol. Swab the area in similar fashion as the phenol swab. The isopropyl alcohol neutralizes the necrotizing effect of the phenol.6–8

An alternative to phenol is silver nitrate. The preferred technique is a phenol matrixectomy. Silver nitrate may be used if phenol is not available. The main disadvantage of silver nitrate is that it turns the tissues black. Insert the silver nitrate matchstick under the eponychium (Figure 184-4). Roll the matchstick around for 5 to 10 seconds to ablate the matrix.

Surgical Nail Matrix Ablation

Surgical excision of the toenail matrix requires more time and experience than chemical ablation.4 This technique is usually reserved for the Podiatrist or the Orthopedic Surgeon. An experienced Emergency Physician can easily perform this technique in the Emergency Department. Expose the nail matrix by retracting the adjacent overlying skin. Make an oblique proximal incision from the proximal corner of the nail if necessary to fully expose the nail matrix in the ingrown area (Figure 184-5A). Make an incision with a #15 scalpel blade to separate the nail matrix to be removed from the remaining nail and matrix (Figure 184-5B). Grasp the corner of the matrix with a hemostat. Use the scalpel blade to separate the matrix from the underlying tissues. Remove the nail matrix. Do not forget to remove the dorsal and deep matrix that envelops the base of the toenail under the skin fold. Remove any remaining nail matrix and nail bed with a curette. Close the skin incision with 5-0 nylon suture.

Electrocautery Nail Matrix Ablation

Electrocauterization of the nail matrix is rapidly performed but requires access to an electrocautery instrument. Apply electrocautery between the roof and the root matrix of the removed nail section to destroy the matrix in this area. Avoid excessive burning of the surrounding tissues. This technique can cause significant damage to normal tissue and should be reserved for the Podiatrist or the Orthopedic Surgeon.

Apply a topical antibiotic ointment and a small compressive gauze dressing over the toe. The patient requires follow-up in 24 to 48 hours for a dressing change and evaluation of the wound. Saturate the dressing with saline or sterile water to make the removal process less painful. Instruct the patient to elevate the foot for the first 2 to 3 days to prevent bleeding and edema. Large shoes, sandals, or cast shoes are best used in the immediate postprocedure days. The use of oral antibiotics is restricted for patients who are immunocompromised, have an associated cellulitis, or whose vascular supply to the toe is decreased. Prescribe nonsteroidal anti-inflammatory drugs supplemented with narcotic analgesics as needed for pain control. Instruct the patient to return to the Emergency Department immediately if they experience increased pain, develop a fever, a purulent discharge, or notice increased redness of the toe or foot. Demonstrate the proper method to trim toenails (Figure 184-6).

Chemical ablation of the matrix with phenol induces a chemical burn. The patient may experience a serous drainage for a few days up to 2 weeks.1 The use of nonsteroidal anti-inflammatory drugs can limit the duration and the amount of drainage.1 Instruct the patient to soak the foot in warm water three times a day for 10 to 15 minutes each time. Apply a topical antibiotic ointment after each soak. Prolonged drainage may be due to a superficial infection and requires evaluation.

The most common complication is the persistence of toenail horns or spikes due to incomplete ablation of the nail and matrix. These can be managed with nail trimming if mild or en bloc excision of the area if severe. Ensure that the portion of the nail is completely removed and that no fragments remain under the nail folds. Use care to not lacerate the nail bed when elevating or cutting the nail plate. Lacerations of the nail bed can bleed significantly, cause chronic pain once healed, and result in a deformed nail. Repair any nail bed lacerations. Refer to Chapter 104 for a complete discussion regarding nail bed repair.

Phenol will deteriorate if it is exposed to air or light. Store the phenol solution in a cool, dark place. Replace the solution frequently. The field must be dry before applying phenol. Phenol mixed with blood results in an alteration of the pH of the phenol, decreasing its effectiveness, and turning the tissues black. The ingrown toenail will recur if the phenol is old or exposed to light before it is used, if the phenol is not properly applied, or if fragments of the toenail or matrix remain. The patient may experience a chemical burn if too much phenol is applied or it is not neutralized with isopropyl alcohol.

An ingrown toenail can be managed easily, quickly, and definitively in the Emergency Department. Perform a partial toenail removal on patients with clinical stage III toenails characterized by pain, overgrowth of inflamed and infected tissue, and drainage. Remove the lateral or medial one-quarter of the nail. Apply phenol solution to the nail matrix to prevent further growth of the nail and a recurrence.