Somewhere in the Sierras there is an 13 year old with a needlessly sore toe. His name is Steve and his mother, Ann, is a personal friend of my wife. He had been backpacking for five days with his father and returned home last Thursday. He left for a week at camp the following Sunday. During his backpacking trip he developed a severe ingrown nail. From the reports his mother received before he returned home on Friday, his big toe was red, swollen and very painful. He wanted to have his toe fixed before he left for camp on Sunday. This meant he and his mother had to work fast.

I told his mother on Thursday night that it sounds like one of the hundreds of ingrown nails I see in teenagers every year. It is not so much an infection as the body’s reaction to an invading nail. The problem starts when the edge of the nail cuts into the toe. The body sees the ingrown nail as a "foreign invader" and tries to get rid of it. The body mounts an attack with white blood cells (pus), red blood cells and various fluids. The net result is a toe that is red, swollen and painful - all this without the benefit of an infection.

For the most part an "infected ingrown nail" is not infected. True, bacteria in the neighborhood can take advantage of this compromised situation. They can sometimes turn an ingrown nail into an infection, but he real damage is the ingrowing nail. Until the nail border is removed, the situation does not resolve. I explained that the use of topical antibiotics, or even oral antibiotics, only treats the infection part which is secondary in importance. They do nothing about the ingrown nail itself. I explained to Steve’s mom that removing the edge of the nail resolves the situation almost overnight. I also explained that podiatrists have developed techniques to accomplish this quickly and as painlessly as possible. Using special techniques we numb the toe to sleep right in the office. With special instruments we remove just the thin border of the nail - just the part that is under the skin. The next day only a Band-Aid is needed for the toe. For most acute cases this is all that is needed. If the problem is chronic, we can modify the technique to make sure the problem never happens again.

Ann was very excited to learn all this and looked forward to having me see Steve on Friday. The only thing standing between her son’s toe and a happy experience at camp was a referral from Steve’s primary doctor. Ann made an appointment with Steve’s doctor for Friday morning and I was set to see him in the afternoon. Last Friday came and went without Steve or Ann showing up at my office.

Ann told me on the following Monday that the primary care doctor refused to grant a referral for Steve’s care. "Not cost effective. We need to see if he responds to a topical antibiotic first", he said. With that, and despite her protests, he gave Ann a prescription for a very fine topical antibiotic and will see Steve when he gets back from his camping trip. He can bet on it.

As I write this, it is a Tuesday. Ann has already heard from Steve that his toe is "killing him" and he is staying close to his cabin. Fixing Steve’s toe would have been quite easy had we been given the chance. Steve is only thirteen but he is already learning of the down side of health reform - the hard way. In this case Managed Care is making one very unhappy camper.

Dr. Michael Zapf is a board certified podiatrist with offices in Agoura and Thousand Oaks. For more information, or his brochure on ingrown nails, you can call his office at (818) 707-3668.