A
Patient's Guide To
Ingrown
Nails
1. 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.
2. 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.
WARNING --> if you want to see the worst case of ingrown
nails I have treated follow this link (warning, this is a very graphic picture)
-->
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.
4.
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.
5.
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/
6. 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.
To see why my injections are thought of as being so gentle please see >
7. 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."
8. 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.
To see my method of doing a matricectomy with full color graphic pictures
please see -->
<--
This is a photographs of a woman who had ingrown nail procedures done by me just
a few days before. Notice that you really cannot tell what side(s) were done
permanently, This if my goal - to fix an ingrown nail such that you cannot tell
anything was done at all. As I say "all you miss is the pain."
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.
7. 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.
1. 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.
2. 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.
3. 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.)
4. Repeat this step twice a day until the drainage from the procedure stops. This will
usually be in about a week.
8. 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.
9. 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.
10. 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.
For
more information please read the articles I have written in the past on ingrown nails here
-->
or
or
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:
Cindy,
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
