(See also Ingrown Toenail Ingrown Toenail An ingrown toenail is incurvation or impingement of a nail border into its adjacent nail fold, causing pain. (See also Overview of Nail Disorders.) Causes of ingrown toenail include tight shoes... read more .)
Inflammation and/or infection around the ingrown toenail
Confirm that the periungual soft tissues (nail fold) are actually extending over the lateral part of the toenail. (Otherwise, consider alternative diagnoses such as trauma, gout Gout Gout is a disorder caused by hyperuricemia (serum urate > 6.8 mg/dL [> 0.4 mmol/L]) that results in the precipitation of monosodium urate crystals in and around joints, most often causing recurrent... read more , paronychia Acute Paronychia Paronychia is infection of the periungual tissues. Acute paronychia causes redness, warmth, and pain along the nail margin. Diagnosis is by inspection. Treatment is with antistaphylococcal antibiotics... read more , or cellulitis Cellulitis Cellulitis is acute bacterial infection of the skin and subcutaneous tissue most often caused by streptococci or staphylococci. Symptoms and signs are pain, warmth, rapidly spreading erythema... read more .)
Nail fold hyperkeratosis, edema, or erythema
Cleansing solution, such as povidone-iodine or chlorhexidine
21- and 25-gauge needles
Local anesthetic, such as 1% lidocaine
Small rubber tourniquet
Elastic or gauze wrapping small enough to surround the toe
English anvil nail splitter, sharp-pointed scissors, or #11 scalpel
Forceps or hemostats
Wound closure strips, 2- to 3-mm diameter surgical drain cut open lengthwise, or a cotton pledget
Silver nitrate sticks, 1% phenol solution, or 10% sodium hydroxide solution
Antibiotic ointment without neomycin
Sterile or nonsterile gloves
Usually with the patient lying supine or sitting and the affected leg straight and well-supported
Step-by-Step Description of Procedure
Several procedures can be done. Some involve only separating and isolating the nail fold from the nail (splinting the nail). Others involve removing part of the nail, either the lateral margin, or a spike-like segment of nail (spicule) growing adjacent to the lateral margin; spicules can develop as a complication of treatment or spontaneously. Sometimes, nail fold tissue is removed. Removal of the entire nail is no longer considered beneficial.
For all procedures
Clean the site with povidone-iodine or chlorhexidine solution.
Do a digital block to fully anesthetize the toe.
Apply a tourniquet at the base of the toe to control bleeding.
Determine extent of treatment based on degree of local soft-tissue inflammation or infection.
If inflammation is minimal, consider splinting the nail or removing only a nail spicule.
If inflammation is more extensive or for infection (particularly chronic) or severe pain, remove part of the nail.
To splint the nail
Elevate the lateral border of the nail with forceps or a hemostat.
Insert a cotton pledget (for mild inflammation), wound closure strip (for moderate inflammation), or 1-cm long strip from a 2- to 3-mm diameter surgical drain under the lateral nail edge.
Insert wound closure strips and surgical drain material, obliquely under the corner of the nail with a to-and-fro sawing motion until the corner is sufficiently elevated and is under the entire length of the nail.
Secure a tape closure around the toe.
To remove a nail spicule
If necessary, elevate the nail spicule with forceps or a hemostat.
Use the nail splitter or sharp-pointed scissors to cut longitudinally between the spicule and the nail plate continuing through the origin of the spicule, about ⅓ to ½ the way under the cuticle to the base of the nail.
Twist the nail spicule from the nail bed with a forceps or hemostat.
Remove any debris from the nail fold.
Control bleeding using silver nitrate.
If an abscess is present, drain all pus, irrigate any cavity, and dress the toe.
To remove all or part of the main part of the toenail
Use the nail splitter or sharp-pointed scissors to elevate the lateral 3 to 4 mm of the affected margin of the nail from the nail bed. Advance the splitter or point of the scissors parallel to the nail bed and go all the way to the proximal nail fold (cuticle).
Cut the nail lengthwise to separate the elevated segment, being sure to also cut the portion of nail under the cuticle.
Grab the segment of nail with forceps or a hemostat back close to the root and twist the segment root toward the rest of the nail, eventually freeing it from the nail fold and cuticle.
Gently retract the nail fold and clean away any hidden debris in epidermis or dermis. Apply a silver nitrate stick to control any bleeding.
Consider applying silver nitrate to the exposed nail bed and granulation tissue for 2 minutes because this tends to prevent nail regrowth.
If available, consider applying 10% sodium hydroxide (for 1 to 2 minutes) or 1% phenol solution on cotton-tipped applicators (3 applications, each about 30 seconds, or a single 5-minute application) to the exposed nail bed to permanently inhibit nail regrowth.
Dress the area with antibiotic ointment and a nonadherent dressing.
For splinted nails, have the patient wash the wound daily and reapply dressing as needed. Remove the splint when the inflammation has resolved and the nail no longer impinges on periungual tissue.
If part of the nail or a spicule has been removed, instruct the patient to soak the toe in warm water 2 or 3 times a day, redress it, and avoid harsh chemicals.
Reinspect the toe in 2 to 3 days for signs of infection, possibly earlier for patients at high risk (eg, those with diabetes, neuropathy, and/or peripheral vascular disease).
If the problem has not resolved, refer for definitive podiatric care.
Instruct patients to wear less constricting shoes and to trim the nail straight across.
Warnings and Common Errors
Be sure to cut all the way to the base of the nail so that no nail is left behind under the cuticle; failure to do so can allow spicule formation and recurrent inflammation.
Be sure to use a tourniquet; otherwise, bleeding may obscure the field.
Look for osteomyelitis in patients with recurrent ingrown toenails, circulatory dysfunction, neuropathy, and/or diabetes.
Tips and Tricks
If a nail splitter is not available, use a sharp-pointed scissors but maintain upward pressure while cutting the nail to minimize injury to the nail bed. Alternatively, use a disposable electric cautery device to cut the nail after softening it by soaking the toe in warm soapy water.
Drugs Mentioned In This Article
|Drug Name||Select Trade|
|Betadine, Betadine Prep, First Aid, GRx Dyne, GRx Dyne Scrub, Povidex , Povidex Peri|
|Betasept, Chlorostat, Hibiclens, Oro Clense , Peridex, Periogard, PerioRx , Perisol|
|7T Lido, Akten , ALOCANE, ANASTIA, AneCream, Anestacon, Aspercreme, Aspercreme with Lidocaine, Astero , BenGay, Blue Tube, Blue-Emu, CidalEaze, DermacinRx Lidogel, DermacinRx Lidorex, DERMALID, Ela-Max, GEN7T, Glydo, LidaMantle, Lidocare, Lidoderm, LidoDose, LidoDose Pediatric, Lidofore, LidoHeal-90, LIDO-K , Lidomar , Lidomark, LidoReal-30, LidoRx, Lidosense 4 , Lidosense 5, LIDO-SORB, Lidotral, Lidovix L, LIDOZION, Lidozo, LMX 4, LMX 4 with Tegaderm, LMX 5, LTA, Lydexa, Moxicaine, Numbonex, ReadySharp Lidocaine, RectaSmoothe, RectiCare, Salonpas Lidocaine, Senatec, Solarcaine, SUN BURNT PLUS, Tranzarel, Xylocaine, Xylocaine Dental, Xylocaine in Dextrose, Xylocaine MPF, Xylocaine Topical, Xylocaine Topical Jelly, Xylocaine Topical Solution, Xylocaine Viscous, Zilactin-L, Zingo, Zionodi, ZTlido|
|No brand name available|
|Castellani Paint, Chloraseptic, Chloraseptic Kids, Phenaseptic, Sore Throat|