Onychocryptosis – decrypting the controversies

Onychocryptosis, or ingrown toenail, is a frequent, painful condition affecting young individuals. Controversies still exist regarding its etiopathogenesis and treatment options, including conservative and surgical techniques. The choice of treatment method depends on the stage of disease as conservative measures are mostly effective in early stages and surgical procedures are required in the later stages. Among surgical techniques, phenol cauterization of lateral nail matrix has been the most effective, safe, and commonly performed method. Other more destructive surgical procedures are rarely done nowadays. In this review, we briefly discuss the etiopathogenesis, clinical features, and different treatment options of ingrown toenail.     

A simple and practical method in treatment of ingrown nails: splinting by flexible tube

BACKGROUND: The ingrown nail (or onychocryptosis) is a common problem that occurs mostly in the big toe and causes high amounts of morbidity in affected patients. Many therapeutic methods have been described, most of them leading to severe damage to the nail or to frequent relapses. The nail splinting technique is a successful, simple and non-invasive therapeutic method for treating ingrown nails. OBJECTIVE: To determine efficacy of the plastic tube insertion technique in patients with ingrown toenail and its use as a standard treatment. MATERIALS AND METHODS: We encountered 32 cases (age range 9-67 years) of ingrown toenails in this clinical trial. All of the patients were treated using the plastic nail tube insertion technique for 7 to 15 days. Patients were examined daily for the first 3 days of treatment and were evaluated 3 and 6 months after treatment. All patients were followed up by a single observer. RESULTS: Recurrence was seen in only two patients after 6 months of treatment (6.25%). CONCLUSION: The low recurrence rate using the nail splinting technique in the treatment of ingrown toenail, as well as its simple application, shows that this treatment constitutes an effective, non-invasive method. It appears that this technique can substitute other more invasive surgical methods, particularly in the early stages of this disease.     

Ingrown and pincer nails: evaluation and treatment

Ingrown toenails are mainly a condition of children and young adults, whereas ingrown fingernail and pincer nails are seen in adults. Their etiology is multifactorial. Different types of ingrowing nails require different treatments. Neonatal ones are always treated conservatively. The hypertrophic lateral nail wall seldom requires surgery. Congenital misalignment of the big toenail may resolve spontaneously, but delay in treatment may cause permanent nail dystrophy. The juvenile type is most common and is treated conservatively in its early stages. Selective matrix horn phenolization or excision is the treatment of choice for later stages. Pincer nails are due to widening of the base of the distal phalanx. Treatment is aimed at reducing the outward pressure of the lateral osteophytes on the matrix horns and permanently flattening the nail. A variety of different methods are discussed.     

Using 80% trichloroacetic acid in the treatment of ingrown toenails

BACKGROUND

Ingrown nails are a very common problem. There are different stages of disease and diverse therapeutic options. Phenol and sodium hydroxide are commonly used agents for chemical matricectomy but both frequently entail excessive healing times.

OBJECTIVE

This prospective study aimed mainly to evaluate the efficacy of partial nail avulsion and selective chemical cauterization of the matrix using 80% TCA in the treatment of the ingrowing nail.

METHODS

One-hundred-and-thirty-three patients with 197 ingrown toenails were included in this study. Preoperatively, we tried to find predisposing factors to the disease. In the postoperative period, patients were evaluated for potential complications at days 3, 30, 180, 270 and 360. Pain was measured before surgery, as well as 24 hours and 72 hours after surgery.

RESULTS

There were only 3 cases (out of 197) of ingrown nail recurrence. Preoperatively, we found the presence of drainage in 82% of patients, which, following the first visit after surgery, was reduced to 19%. Persistent granulation tissue was found in 3% of the patients (versus 75% prior to surgery). The most frequent predisposing factors for the ingrown nail were excessive trimming of the lateral nail plate (63%), plantar hyperhidrosis (58%) and heavy nail folds (39%). Pain was substantially reduced after surgery.

CONCLUSION

It is assumed that chemical procedures for the ingrown toenail are associated with delayed healing times but our results demonstrated quick recovery. Using 80% TCA for selective matricectomy in the ingrown toenail is an effective, quick and easy method.     

Evaluation and treatment of nail disorders utilizing practical nail surgical techniques

Nail disorders frequently seen in daily practice may be inflammatory, infectious, tumoral, traumatic, or cicatricial. Surgical correction of the most common disorders is reviewed here. Treatment of the different types of ingrown nails as representative of the inflammatory diseases, the peculiarities in the treatment of an acute or a chronic hematoma, management of infectious diseases like chronic and acute paronychia, and different surgical techniques to treat a nail tumor depending where the problem is located, trying to prevent permanent postsurgical dystrophies are discussed.     

Ingrown toenails

Ingrown toenails are common, especially in young patients. Several predisposing factors contribute to the formation of an irregular sharp edge (spicule) of the lateral nail plate that penetrates and injures the soft tissue of the lateral nail fold. Depending on the severity of the disease, treatment varies from simple disembedding of the spicule to phenolization of the lateral nail matrix. This article provides a step-by-step guide to the management of patients with ingrown toenails.     

Ingrown nails and pachyonychia of the great toes impair lower limb functions: improvement of limb dysfunction by medical foot care

Background Painful feet and lower limb dysfunction are risk factors for falling. Toenail deformities are common disorders in elderly people, but the relationship between nail deformities and lower limb function remains unclear. The aims of the present study were to assess the impairment of lower limb function in patients with deformities of the great toe and to determine whether foot care treatment is beneficial in reducing the risk of falling. Methods Functional tests of the lower extremities were performed in 263 adults, including patients with any of hallux valgus, ingrown nail, or pachyonychia, and volunteers. Fifty‐five subjects with nail disorders of the great toe received medical foot care treatment. Results The presence of ingrown nail, pachyonychia, or tenderness of the great toe was significantly correlated with impaired postural performance and reduced muscular strength as assessed by functional tests. Medical foot care markedly reduced pain levels in the great toe and improved scores on functional tests of the lower extremities. Conclusions Toenail disorders of the great toe cause dysfunction of the lower extremities and are likely to increase the risk of falling in daily life. Foot care management of toenail disorders has the potential to improve functional abilities in daily life, particularly in elderly individuals.     

Ingrown toenails: an evaluation of elevating the nail bed-periosteal flap.

Many procedures to correct ingrown toenails are available; however, they cannot avoid recurrence and nail deformities. We have performed a procedure which corrects ingrown toenail without reducing the width of the nail plate by elevating the nail bed-periosteal flap. Sixty patients were observed for longer than six months and exhibited excellent results. Only two cases of incurvated nails (2) required re-operation.     

Treating ingrown toenails by nail splinting with a flexible tube: an Indian experience

Ingrown toenail is a common problem, and currently available treatments are either quite invasive or associated with unacceptably high recurrence rate. Recently a new non-invasive therapy. "Nail splinting", has been introduced. In this procedure, the nail is splinted with a longitudinally incised plastic tube. We conducted the present study to evaluate the efficacy and safety of this procedure in fifty patients (68 nail edges in 61 nails) with ingrown toenails at all stages. The pain disappeared almost immediately, and inflammation subsided in about one week in all nail edges. Thirty-nine patients came for regular follow-up for six months after removal of the tube. Eight (20.5%) of these patients showed recurrence of the problem. No serious side effects were noted.     

Treatment of ingrown nail with a special device composed of shape‐memory alloy

Ingrown nail is a common nail problem resulting in pain and disability in daily life. Recently, a new treatment modality for an ingrown nail was reported that used a device composed of shape‐memory alloy, K‐D. The aim of the present study was to determine the efficacy, recurrence rate and complications of K‐D. Between June 2010 and September 2012, 24 patients (31 nails) underwent treatment of symptomatic incurved nails with a K‐D. Patients were evaluated at pretreatment and during every visit. The mean age of the patients involved was 43.4 years. The mean period of follow up was 161 days. The mean maintenance period was 41 days. The right first toenail was the most common site. Almost ingrown nails healed and the nail deformity was corrected after the procedure. Among the 31 nails, seven of the ingrown nails recurred during follow up (22.6% recurrence rate). The recurrence rate of the patients with stage 1, 2 and 3 ingrown nails was 22.2%, 33.3% and 14.2%, respectively. The majority of patients were very satisfied. There were no side‐effects in most patients except loss of nail in one patient. K‐D has some advantages such as simple application steps, no deformity after the procedure, high patient satisfaction and obvious effect compared to other non‐invasive and invasive methods.     

Comparación de 2 técnicas de bloqueo anestésico en el tratamiento quirúrgico de onicocriptosis del primer dedo del pie

Background and objectiveSurgery for an ingrown toenail of the great toe is a common procedure that requires an anesthetic neuromuscular blockade of the entire digit. Various digital block techniques have been described, but no evidence-based recommendations on the best choice have emerged. We aimed to compare the V block to the H block in this type of surgery.Material and methodsMulticenter randomized clinical trial in patients undergoing onychocryptosis surgery between February 2018 and February 2020. We recorded sex, age, foot intervened, type of blockade used (H block or V block), efficacy 10 and 20 minutes after injection of the anesthetic, and number of attempts.ResultsA total of 140 surgeries to treat ingrown toenails were assigned to 2 groups (H block or V block) of 70 patients each. The same anesthetic, dose, and volume were used in all cases. The V technique produced a better neuromuscular block in 7.2% more cases at 10 minutes and in 12.8% more at 20 minutes.ConclusionsBoth block techniques are safe and effective. The V block is a good alternative to the H block in patients undergoing surgery to treat an ingrown toenail.     

Surgical management of ingrown toenails – an update overdue

For decades, every year sees a wide number of articles about treatment of ingrown toenails. There is still a debate about the cause of this painful condition. Surgical treatments rely on two main approaches: either narrowing the nail plate or debulking the soft tissues. It is up to the surgeon to select the most appropriate approach in each case. All procedures cited in this article have high cure rates as long as they are properly performed. As with all surgical procedures, they are operator dependent. Chemical cautery is the easiest and most versatile technique that may help in almost all instances for lateral ingrowing. For distal embedding and very hypertrophic and exuberant lateral folds, debulking with secondary intention healing is the most effective and easy to perform, with great results.     

[Translated article] Comparison of 2 Anesthetic Techniques in Onychocryptosis Surgery of the Great Toe: A Randomized Clinical Trial

Background and objectiveSurgery for an ingrown toenail of the great toe is a common procedure that requires an anesthetic neuromuscular blockade of the entire digit. Various digital block techniques have been described, but no evidence-based recommendations on the best choice have emerged. We aimed to compare the V block to the H block in this type of surgery.Material and methodsMulticenter randomized clinical trial in patients undergoing onychocryptosis surgery between February 2018 and February 2020. We recorded sex, age, foot intervened, type of blockade used (H block or V block), efficacy 10 and 20 min after injection of the anesthetic, and number of attempts.ResultsA total of 140 surgeries to treat ingrown toenails were assigned to 2 groups (H block or V block) of 70 patients each. The same anesthetic, dose, and volume were used in all cases. The V technique produced a better neuromuscular block in 7.2% more cases at 10 min and in 12.8% more at 20 min.ConclusionsBoth block techniques are safe and effective. The V block is a good alternative to the H block in patients undergoing surgery to treat an ingrown toenail.     

A comparison between CO2 laser surgery with and without lateral fold vaporization for ingrowing toenails.

BACKGROUND: An ingrowing toenail is an excessive lateral nail growth into the nail fold. It acts as a foreign body and exerts a local pressure sore-like effect, which may result in inflammation and granulation. Several treatment modalities exist, including chemical ablation and different surgical procedures. Here we describe and compare a simple and effective method of partial matricectomy using the CO2 laser (group A) versus a similar method with the addition of lateral nail fold vaporization (group B). OBJECTIVE: Outcome evaluation of a modified laser treatment modality for ingrowing toenails and determination of the role of lateral fold vaporization in reducing the recurrence of symptoms. METHODS: Forty patients (mean age 32.45 years) were treated with CO2 laser ablation of toenails between 1999 and 2005 by four physicians. One physician implemented a method that includes lateral nail fold vaporization and resection of the nail segment with its nail bed from 1999 to 2005. Three physicians implemented a similar technique but without lateral fold vaporization between 1999 and 2003, and added lateral fold vaporization to the performed procedure starting in 2004. RESULTS: The recurrence rate was 37.5% in group A and 6.2% in group B. The overall average disease-free follow-up period was 42.2 months. CONCLUSION: The use of CO2 laser in the treatment of ingrowing toenails offers an effective modality. We demonstrate the importance of lateral fold vaporization with the CO2 laser both in improving efficacy and in decreasing recurrence rates over a long follow-up period.     

Nail changes during childhood

Nail changes occur frequently in adults, but are relatively rare in children. There are, however, certain nail changes that emerge particularly during childhood. Ingrown nails, onychoschizia, congenital slanted alignment of the large toenail, and psoriasiform nail dystrophies can be frequently observed in toddlers and in schoolchildren the syndrome of an ingrown nail, nail artifacts, periungual warts or fibromas, trachyonychia, and nail mycoses. Connatal nail changes can appear as isolated events or together with other symptoms whereas acquired nail changes are caused by infections, traumatic injuries, or tumors, in conjunction with skin diseases or general illnesses, or even develop spontaneously.     

Pincer nail: aesthetic concept in surgery

Although pincer nail deformity (PND) treatment is time consuming independent of whether it is based on surgical or conservative procedures, long lasting beneficial results are found only after surgical intervention. Typically destruction of the lateral matrix horns either surgically or by phenol cauterization or even ablation of the matrix is performed. In the past these procedures mainly aimed at relief from pain; however, currently more patients ask for the preservation of the nail unit and a good cosmetic outcome. Today reconstructive results that meet the patient expectations are available. An adapted novel surgical method which will preserve the matrix horns while correcting the shape of the phalanx and preventing renewed adhesion of the nail bed to the phalanx is presented. Therefore the restoration of a normal width-to-length ratio of the nail plate with a cosmetically appealing result becomes possible. Surgical steps in an affected right toenail are presented.     

Current topics in nail surgery

BACKGROUND: Nail surgery can be performed in an office-based dermatology practice with a limited amount of specialized equipment and training. Several excellent reviews have been published in recent years that detail the techniques of nail surgery for both the novice and the experienced practitioner. OBJECTIVE: In this article recent developments in nail surgery are discussed. Topics that are treated include the general principles of nail surgery, including epidemiologic issues, studies of nail anatomy, instrumentation, and anesthesia. The reconstruction of injuries and congenital defects involving the nail is explained, and the role of the hand surgeon clarified. Appropriate removal of tumours and cysts is considered, with special attention to the management of malignant lesions. The controversy regarding more or less conservative management of melanonychia striata is addressed, and the need for early diagnosis of subungual melanoma is emphasized. Other topics are surgical management of ingrown nails and onychomycosis. Newer areas of nail surgery, such as laser surgery of the nail, psychodermatology of the nail, and the role of primary care physicians in simple nail surgery are also examined.     

部分甲基质切除甲沟重建治疗嵌甲

目的研究1种利用甲侧襞皮瓣改变甲体与甲沟的位置结构,从而彻底治愈嵌甲的手术方法。方法切除部分甲体、甲床,并利用甲侧襞皮瓣重建甲床、甲沟、甲侧襞联合结构。结果2000年1月～2003年5月对158 例嵌甲患者,足趾209、手指3,共276侧嵌甲进行甲沟重建手术。随访6月～2年,效果满意。结论该手术从根本上治愈嵌甲,且并发症少,复发率极低。     

Congenital malalignment of the great toenails in dizygotic twins

Congenital malalignment of the great toenails is a nail disorder caused by the malalignment of the nail matrix, which results in lateral growth of the nail plate. It may cause onychogryphosis and, in infants and children, ingrown nails. We report an occurrence of this deformity in dizygotic twins.     

Nail alterations in 250 infant patients: a clinical study

Aims To investigate the frequency and the nature of nail alterations in infants. Study design A total of 250 infant patients from newborn to 2 years of age were evaluated from the outpatient clinics of paediatrics and dermatology departments, Fatih University Hospital. The nail alterations were documented. The data were presented as percentages, and for categorical comparisons, Chi‐squared or Fisher's Exact test were used. P < 0.05 was considered statistically significant. Results Of the 250 infant patients, nail alterations were seen in only 17 (6.8%). Most of the patients had toe nail involvement. In 12 of 17 (70.6%) infants, there was one type of nail alteration; in 4 of 17 (23.5%) infants, there was two type of nail alterations; and in 1 of 17 (5.9%) infants, there was three type of nail alterations. The most frequent diagnosis was onychoschizia in 6 of 17 (2.4%) and congenital hypertrophy of the lateral nail fold together with ingrown nail in 6 (2.4%) infants. Conclusion Because nail alterations could be a manifestation of systemic or dermatologic diseases in infants, fingernail and toenail examination should be a part of the paediatric dermatology examination.