Ingrown toenail treatment

Photo of a foot bath (PantherMedia / Kzenon)

If a toenail grows into the skin, it can lead to a painful inflammation. In mild cases, treatments like antiseptic creams are often enough. But surgery may be needed if the ingrown toenail is chronically inflamed or produces pus.

Ingrown toenails are common. There are a number of different treatment options, depending on how severe the symptoms are.

Things like creams, small pieces of cotton wool or toenail braces are usually enough to relieve mild symptoms. You don't have to go straight to the doctor. If you feel unsure about the treatment, you can see a podiatrist (foot specialist).

If these treatments don’t help or if the ingrown toenail hurts a lot, produces pus or is constantly inflamed, surgery is an option. This usually involves cutting out the inflamed tissue and removing about one third of the toenail, or sometimes even the entire nail.

What can you do yourself?

First, you can try to clean the painful part of your toe in warm soapy water and let it soak for about 10 to 20 minutes. The skin can then be pushed back a little from the edge of the toenail so that the small wound can be treated. It’s important to carefully dry your foot afterwards. Antiseptic and anti-inflammatory tinctures, gels and creams prevent infection and soothe the skin. But you shouldn’t put too much on, or the tissue may become too soft.

The goal of treatment is to relieve the symptoms and allow the ingrown toenail to grow normally again.

This also includes making sure that nothing presses against the ingrown area – not even the neighboring toes. A small silicon or foam wedge kept in place with gauze can help to separate the toes.

There are also special tools for keeping the edge of the nail permanently pushed away from neighboring skin (lateral nail fold) so that it can grow freely again. Some are available at drugstores and pharmacies without a prescription. You don't need to go to a doctor. But it may help to see a podiatrist (foot specialist). Whether and when the different treatments are especially suitable still needs to be tested in scientific studies. The options are:

  • Cotton wedges: Here the nail is carefully lifted and a sterile piece of cotton is placed between the nail and the skin.
  • Taping: This involves applying adhesive elastic tape to pull the inflamed skin away from the edge of the nail.
  • Toenail braces: Braces are placed on the nail and hooked into place behind one or both corners of the nail. This lifts the nail slightly. There are also braces that are stuck on to the toenail and don't need to be attached with hooks.
  • Plastic gutter splints (sleeves): These are pushed over the edge of the nail to separate the nail from the skin.

 

Illustration: Brace or splint as a treatment option - as described in the articleBrace or splint as a treatment option

Treatments like braces or splints typically have few side effects, but you have to be patient: Sometimes it can take several months for the nail to grow out of the inflamed area. They’re also not suitable for everyone: If, for instance, you have numbness in your feet due to diabetes or if the toe is already infected, you should talk with a doctor before using any of these non-surgical treatments.

What happens during surgery?

If the symptoms don't improve after trying things like foot baths, bandages with creams or braces, or if the ingrown toenail has been severely inflamed, oozing pus or very painful from the beginning, doctors usually recommend surgery.

There are different types of surgery for ingrown toenails. In smaller procedures, the inflamed tissue along the side of the nail is removed (excision of the nail fold, also known as the Vandenbos technique). This gives the nail more space again. Sometimes only the edge of the ingrown toenail is cut off (wedge resection).

Major procedures: Partial nail avulsion and total nail avulsion

In most cases, though, doctors carry out larger procedures to try to remove the inflamed tissue and the affected part of the nail, right down to the root of the nail.

Partial nail avulsion is one common type of surgery that aims to do this. In this procedure, one third of the nail is cut out on the side where it is ingrown, and the inflamed tissue is also removed. Sometimes it’s enough to just cut out about one quarter of the nail. To close the wound, the surgeon then stitches the side edge of the remaining nail together with the remaining skin. It is sometimes a good idea to leave the wound open while it is healing – for example, if it is very severely infected. If the nail is growing into the skin on both sides, it may be completely removed instead.

People are advised to keep their foot elevated for a while right after the procedure. The wound pain can be relieved with painkillers. If there are stitches in the wound, they are usually pulled ten days after the surgery. If the wound is left open, it needs to be checked and the dressing needs to be changed regularly during the first few weeks, for example by your family doctor.

Partial removal or ablation of the nail matrix

Surgery should also guarantee that the nail doesn't become ingrown again later on. The nail matrix, which is like a pocket that the lower end of the nail is tucked into, plays an essential role in this. The cells in the nail matrix are responsible for the continuous growth of the toenail. But nail growth can cause problems again later on. So doctors not only try to remove the affected part of the nail, but also the part of the nail matrix that goes with it, especially if the ingrown toenail has come back again in the past. That part of the nail matrix is then cut out or scraped out. This makes the nail permanently narrower. Another way to destroy that part of the nail matrix is using a corrosive liquid such as phenol or sodium hydroxide. Alternatively, it can be destroyed with heat, for instance using an electric current (electrocauterization) or a laser. Procedures that destroy the tissue are known as ablation.

Anesthetic

The various procedures can usually be done without a general anesthetic – a local anesthetic is enough. It is injected into the base of the toe. Sometimes a sedative is injected instead, so that you are asleep during the operation. The toe is also tied off with a rubber band to keep the incisions (cuts) from bleeding too much during the procedure.

What are the risks associated with the different procedures?

The general possible complications of surgery include wound infections, poorly healing wounds, bleeding and damage to nerves. If the nail is removed, there is also a risk that the toe’s extensor tendon will be injured, resulting in restricted movement of the toe.

Wound infections, bleeding and pain occur equally often in all of the procedures. The surgical wounds also heal at a similar rate – within about two weeks. Using antibiotics doesn’t lower the risk of wound infections or speed up the healing process.

Which treatment is most likely to prevent the toenail from becoming ingrown again?

If someone has already had an ingrown toenail, it's only normal to try to stop the nail from causing problems again. Scientific research shows that the risk of another ingrown toenail is lower following surgery than after using a plastic gutter splint: Within one year,

  • about 49 out of 100 people develop another ingrown toenail after treatment with a gutter splint,
  • compared to about 31 out of 100 people who have surgery.

Several studies have also looked into whether surgery is more effective at preventing the development of new ingrown toenails if the nail matrix is destroyed (cauterized) using chemicals too. But the studies often compared different types of procedures with each other. So the only conclusion that can be drawn so far is that larger operations with additional nail matrix cauterization are more likely to prevent an ingrown toenail form returning than smaller procedures with cauterization.

There was only one study in which all 123 participants had the same kind of surgery: They all had a part of their nail removed. In 63 people, the corresponding part of the nail matrix was cauterized using phenol. This additional cauterization reduced the risk of a recurrence:

  • 41 out of 100 people who had surgery to remove part of the nail developed an ingrown toenail again within one year.
  • If the corresponding part of the nail matrix was cauterized during the procedure too, the ingrown toenail grew back in only 14 out of 100 people.

So this additional phenol treatment may prevent an ingrown toenail from developing again in 27 out of 100 people. But it still isn’t clear what the exact advantages and disadvantages of nail matrix cauterization are. This is because the scientific quality of the studies wasn't as good as it could have been.

Labels: Disorders of the nails, Ingrown nail, L60, Nail disorders, Onychocryptosis, Skin and hair, Unguis incarnatus