A Patient's Guide To Ingrown Nails
- What is the purpose of a toenail, anyway?
Nails are composed of keratin – the same protein that makes up hair. The nails are just a more compact and hard form. Unlike common wisdom, nails do not protect the very sensitive tip of the fingers or toes. If you were to have a nail removed, the skin under the nail would harden in a few days and it wound not be sensitive. The two official purposes of the nail are for support to pick up little objects and, believe it or not, scratching.
Nails support the back of the finger and toe pads. This gives the tips of the fingers and toes enough firmness that we can pick up objects like paper clips and jellybeans. If you argue that we, as humans, do not pick things up with our toes, I will agree. But the design is very apparent if you look at what apes and monkeys can accomplish with their feet. Theirs are shaped like hands, with opposable big toes, and they do pick things up with their feet and toes
The second purpose of nails is to scratch. Without your nails scratching would not be the very satisfying experience you have come to know and expect. Scratching is especially important in the animal kingdom. At your next visit to the zoo watch how the non-human primates pick nits and other small vermin off of each other using their fingers and toes.
A third reason is to keep podiatrists busy. We see many ingrown nails.
- What is an ingrown nail?
Simply put a nail is classified as "ingrown" when it digs into the side of the toe. At first you may only notice a little soreness in some shoes or with tight socks. A more severe ingrown nail starts to hurt with a wider variety of shoes. A severe ingrown nail is obvious: the toe next to the nail is red, swollen, hot and very painful.
Teenagers commonly get the ACUTE version, the ones I call the "drippy-drainy" ingrown nails. Teenagers respond with a very aggressive immune response that is comprised of white cells (pus), red cells (blood) and edema (edema.) Most of this response is due to the attempt by the body to attack the "foreign" invader" nail and the response can be correctly called a foreign body response. Unfortunately the nail is too big and thick for the body to dissolve and the problem festers until the nail border is removed. As soon as the nail border is removed the problem will resolve. All too often I see young patients who have received two or three courses of antibiotics for an ingrown nail when simply removing the nail border would have solved the problem within a few hours.
Adults are more likely to get a CHRONIC version. Often times a chronic ingrown nail looks rather normal. The only symptoms are pain with pressure, such as a shoe. Chronic ingrown nails are no less a problem than the acute ones, although they do not get the same "oohs and ahhs" when I show slides of them in my community and school lectures.
3.Will cutting a “V” in the end of the nail help?
Unfortunately cutting a "V" into the tip edge of the nail will not help it at all, and in fact, it could make the problem worse. An ingrown nail is painful at the side of the toenail and a correction needs to be addressed there. Cutting a "V" into the tip of an ingrown nail helps no more than cutting a "V" into the top of a door will help a sticking door. To free the door you would have to plane the sides of the door just a bit. The same principle works for ingrown nails, as I will soon explain.
- Will taking antibiotics help?
Typically antibiotics will not help true ingrown nails. The problem is the side of the nail plate that has grown into the side of the toe. If this unfortunate situation gets further complicated with a bacterial infection then antibiotics will help, but only with the infection. The edge of the nail is still in the side of the toe and needs to be addressed.
- A patient asks: "My father had an ingrown nail removed years ago. It was very messy, done at the hospital and he had stitches and lots of problems. Will this happen to me?"
Unfortunately in the past (and even more unfortunately still today in some places) ingrown nails were treated on a "grand scale." The procedure was done in the hospital under (sometimes general) anesthesia and involved long incisions, sutures and lots of unnecessary bleeding. Fortunately this is no longer the case. I still see patients with the tell tale scars on their toes from these big procedures. Unfortunately I do not see them all that often because they are often afraid to venture into a foot doctor's office, again. I thrive, however, on patients who have had bad experiences in the past. I can usually comfort them, gain their confidence and do what needs to be done.
- Dr. Zapf, how do you treat ingrown nails?
The first step is to take a careful history: is this a recent ingrown nail or a chronic one, is there a family history of ingrown nails, was there a similar situation on the same toe of the other foot is the past?
First time ingrown nails are often treated with a simple partial avulsion, medical speak for gently removing the very edge of the nail. This is done under local anesthesia. I have developed several techniques to make sure the local anesthesia is very, very gentle. Once the toe is numb, the very edge of the nail is removed and the problem is solved. The toe is dressed with a bandage and you leave with a prescription for a topical antibiotic. The next day all you do is remove the dressing, clean the toe, apply the antibiotic and dress the toe with a simple Band-Aid. There is typically no pain in the toe the next day. The only pain you have is brief and occurs when the anesthetic wears off if the toe/foot is not elevated. After two or three days the toe is healed and the problem resolved.
- But what if my ingrown nail has come back or lasted a long time?
Then I recommend a technique known as a partial matricectomy (pronounced may-tris-ek-toe-me but you can just call it "that permanent nail procedure" and we will know what you mean). The matrix is the root tissue. After removing a thin edge of the ingrown nail plate, a chemical is used to kill the root cells behind just the edge of the ingrown nail. This will prevent the ingrown nail forever and not appreciable change the appearance of the nail. Done perfectly, no one should ever know a surgical procedure was done on the nail. It is a very cosmetic procedure and would make any plastic surgeon proud. I am fond of saying, "All you miss is the pain."
- But my friend (mother, sister, etc.) had it done and her nail(s) look terrible. They are thin little nails that are not the least bit cosmetic and she is embarrassed to show them to anyone.
I agree that some doctors take way too much nail and the result is a thin little "cat claw" growing on the top of the toe. I never do this. When I lectured and taught at the L.A.County/U.S.C. Medical Center Podiatry Department I was appalled at the amount of nail that some students and residents were removing when doing this procedure. I made my students and residents take a much more cosmetic amount of nail. If I do not do your nail procedure, I hope that you get one of my students.
She reported that she did not have any pain whatsoever and was able to wear closed shoes the following day.
I know that some offices make a "big deal" out of doing a permanent ingrown nail surgery. That is not how Dr. Payne and I do it. We perform the procedure right in the office under local anesthesia and it takes, maybe, 20 minutes from start to finish with little or no stress.
9. So how long will I be out of commission with the permanent nail procedure?
Postoperative care of the partial matricectomy (permanent nail procedure) is quite easy.
- Return home and elevate the foot above the level of the heart (toes to the nose) for a few hours or until the local anesthesia wears off.
- The next morning shower or bathe as usual leaving the dressings in place. After you finish the shower or bath remove the dressings and the clean the nail borders using any of these three methods that are all interchangeable:
- a) Let some clean water from the shower or tap splash into the toe border while you clean it with a Q-Tip.
- b) Soak your foot in an Epsom Salts (or table salt for that matter) solution for a few minutes while you clean the nail border with a Q-Tip
- c) Drip some hydrogen peroxide onto the toe and clean the border with a Q-Tip.
- After cleaning the toe apply the antibiotic, depending on what you were prescribed. If you were given a prescription for eardrops (yes, eardrops) then apply a drop the antibiotic Cortosporin otic (ear drops!) into the nail border and cover with a Band-Aid. If you were given a prescription for Silvadene or Bactroban, then put a dollop onto the sterile non-stick pad of a Band-Aid and then place it onto your toe. Placing the antibiotic cram on the band-aid and not the toe preserves the cleanliness of the tube of antibiotic (that is, you do not contaminate it.)
- Repeat this step twice a day until the drainage from the procedure stops. This will usually be in about a week. 10. Who should do your permanent nail procedure?
Certainly all podiatrists are experienced in this procedure and you should be able to expect most of us to do a great job. There are many family doctors, dermatologists, orthopedic surgeons and plastic surgeons that also do nail surgery with varying degrees of success. Make sure that the doctor you select does nail surgery on a regular basis. It is not unreasonable to ask the office staff how many nail procedures the doctor does. This is especially important when you have your nails treated at an emergency room or urgent care. At these facilities you might see anybody from an emergency rood specialist to a moonlighting dermatologist or a moonlighting radiologist. Quality of nail surgery can vary. A note of caution, if you see an E.R. doc, or anybody for that matter, start by injecting the toe from the tip, by the nail, instead of at the base of the toe where it joins the foot, run away quickly. This person does not know how to treat an ingrown nail and the injection will be extremely painful.
11. Should they be Board Certified?
For any precise bone work your foot surgeon should be Board Certified. For nail procedures it is not as important as long as your doctor sees and does a lots of nail surgery.
12. What can go wrong?
The success rate for ingrown nail surgery is very high, probably in the upper 90 percentile. Complications include infection, prolonged numbness along the side of the toe and a prolonged healing time, which sometimes requires the toe to be anesthetized and cleaned out. About 2-4% of the time some or the entire nail border can "regrow" requiring a repeat of the procedure. An unusual complication is the nail no longer growing straight but, instead, growing a bit diagonally. While it is rare it is by no means unheard of. This is not a reason to avoid he procedure but it is a reminder to have the best doctor you can get do your nail surgery.
This is an internet letter I received about nail procedures:
Hey doc - hope you can help (or point me in the right direction)... Last summer I had the procedure to remove ingrown toenails (both big toes - both sides) - It'll be a year in June & my toes are feeling really strange. They are numb to the touch and the insides tingle and hurt. It sounds weird and I'm embarrassed to go to my primary care doc without any information...Do you have any suggestions???
And my answer:
I am sorry you are having this problem. It is very uncommon.
Do you know the type of procedure you had done? Chemical? Surgical? Laser?
I did have a colleague who had a patient with this problem and I had a chance to read the records. I, frankly, could find nothing that was done that could be responsible for the pain and problem. Her toe actually got a bit red at times, does yours? The eventual outcome was that she had a thing called Reflex Sympathetic Dystrophy (SD) now called Regional Complex Pain Disorder (RCPD). It is where the body seem to over-react to an otherwise minor trauma. You might want to do as follows: 1) do not be afraid or embarrassed to tell your primary - these things can happen to anybody. 2) Consider seeing a board certified podiatrist to make sure that the borders are very clean and there is nothing in there to be causing the pain (this is unlikely since you report the problem on both toes) 3) see a neurologist to rule out RSD/RCPD
Future treatment could involve a so-called "wedge-resection" where a little "V" shaped piece of tissue is removed from the borders of the toes (the old fashioned way of doing a nail procedure) (your podiatrist knows these as a Winograd procedure). Here the nail border and all the surrounding tissues (and nerves ) are removed at one time.
I hope this helps.
Michael Zapf, DPM