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Ingrown Toenail

(Onychocryptosis)

by Wingfield E. Rehmus, MD, MPH

An ingrown toenail is incurvation or impingement of a nail border into its adjacent nail fold, causing pain.

Causes include tight shoes, abnormal gait (eg, toe-walking), bulbous toe shape, excessive trimming of the nail plate, or congenital variations in nail contour (eg, congenital pincer nail deformity). Sometimes an underlying osteochondroma is responsible, especially in the young. In the elderly, peripheral edema is a risk factor. Eventually, infection can occur along the nail margin (paronychia—see Acute Paronychia).

Symptoms and Signs

Pain occurs at the corner of the nail fold or, less commonly, along its entire lateral margin. Initially only mild discomfort may be present, especially when wearing certain shoes. In chronic cases, granulation tissue becomes visible, more often in the young.

Diagnosis

  • Clinical evaluation

Redness, swelling, and pain suggest paronychia. In young patients (eg, < 20 yr) with recurrent ingrown toenails, x-rays should be considered to exclude underlying osteochondroma. In the elderly, apparent granulation tissue around the toe suggests the possibility of amelanotic melanoma, which is often overlooked; biopsy is necessary.

Treatment

  • Usually nail excision and destruction of adjacent nail matrix

In mild cases, inserting cotton between the ingrown nail plate and painful fold (using a thin toothpick) may provide immediate relief and, if continued, correct the problem. If the shoes are too tight, a larger toe box is indicated. In most cases, however, particularly with paronychia, excision of the ingrown toenail after injecting a local anesthetic is the only effective treatment. After excision, a flexible tube can be used to separate the nail plate and painful fold and allow healing. If ingrown toenails recur, phenol is applied to permanently destroy the nearby lateral nail matrix. Phenol should not be used if there is arterial insufficiency.

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