Ingrown Toenails

What Is an Ingrown Toenail?

An ingrown toenail, also known as onychocryptosis or unguis incarnatus, is a painful condition of the toe. It occurs when a sharp corner or edge of the toenail digs into the skin at the end of or side of the toe. Pain and inflammation at the spot where the nail curls into the skin occurs first. Later, the inflamed area can begin to grow extra tissue or drain yellowish fluid.

  • If left untreated, an ingrown toenail can progress to an infection or even an abscess that could require surgical treatment.
  • Ingrown toenails are common in adults and adolescents but less common in children and infants. They are more common in men than in women. Young adults in their 20s or 30s are most at risk.
  • Any nail can become ingrown, but the condition is usually found in the big toe.

What Are Common Causes and Risk Factors of an Ingrown Toenail?

  • Tight-fitting shoes or high heels cause the toes to be compressed together and pressure the nail to grow abnormally.
  • Improper trimming of toenails can cause the corners of the nail to dig into the skin. Nails should be trimmed straight across, not rounded.
  • Disorders such as fungal infections of the nail can cause a thickened or widened toenail to develop.
  • Either an acute injury near the nail or any trauma that causes the nail to be damaged repetitively (such as playing soccer) can also cause an ingrown nail.
  • If a member of your family has an ingrown toenail, then you are more likely to develop one, too. Some people's nails are normally more rounded than others or the underlying bone can be more "upturned," which increases the chance of developing ingrown nails.

What Are Ingrown Toenail Symptoms and Signs?

An ingrown toenail is a common disorder that most often affects the outer edges of the nail of the big toe (hallux) most frequently. However, the nail on any toe can become ingrown. The most common signs and symptoms are pain, redness, and swelling at the margins of a toenail.

  • Early in the course of an ingrown toenail, the end of the toe becomes reddened and painful with mild swelling. There is no pus or drainage. It may feel warm to the touch, but you will not have a fever.
  • Later, extra skin and tissue will grow around the sharp point of the nail. A yellowish drainage may begin. This is the body's response to the trauma of a nail irritating the skin and is not necessarily an infection.
  • Sometimes an infection develops. In this case, the swelling will become worse, and there may be white- or yellow-colored drainage (pus) from the area. A lighter-colored area of the skin may be surrounded by red skin. A fever may develop, although this is unusual.

When Should Someone Seek Medical Care for an Ingrown Toenail?

Anytime an ingrown toenail has developed into an infection it is wise to seek medical attention. Even if the ingrown toenail is only inflamed without infection, see a doctor if the following conditions also occur:

  • If it has been more than five years since the last tetanus booster shot
  • If there is no improvement after three days of home care
  • If someone has diabetes, poor circulation, AIDS, are on chemotherapy, or have another reason for poor wound healing or an increased risk of infection

Most ingrown toenails can be managed in the doctor's office. However, go to the emergency department (by car, not ambulance) if these circumstances develop:

  • If you have diabetes or are at increased risk for infection and your regular physician is unavailable (even if the toe is not infected yet)
  • If you have diabetes or are at increased risk for infection and have any fever or signs of infection in the toe (Both bacterial and fungal infections are more common in immunocompromised people.)
Treatments for ingrown toenails include OTC nail products and surgery.

Ingrown Toenail Treatments

A number of over-the-counter treatments for ingrown toenails are available. These topical nail products may contain botanical ingredients like menthol and tea tree oil to decrease inflammation. Other topical agents may contain salicylic acid, which relieves pain and softens nails. Over-the-counter remedies should not be used by those who have diabetes, poor circulation, or an infection of the foot.

What Specialists Treat Ingrown Toenails?

Family physicians, podiatrists, orthopedic surgeons, hand surgeons, and dermatologists should all be able to diagnose and treat patients with ingrown nails. All of these physicians are able to treat ingrown fingernails as well, aside from podiatrists whose scope of practice is confined to problems below the ankle.

What Tests Do Health Care Professionals Use to Diagnose an Ingrown Toenail?

The doctor will decide if an infection is present and how to treat it.

  • The doctor will evaluate an ingrown toenail by asking how the problem developed (if any injury, when it started) and about other medical problems, medications, allergies, and most recent tetanus immunization.
  • A physical exam will include checking the patient's temperature, pulse, and blood pressure, performing a detailed examination of the foot, toenail, and the lymph nodes in the groin, and possibly doing an X-ray of the foot.
  • Blood tests may be performed if there is a severe infection or a history of diabetes.

What Are Ingrown Toenail Home Remedies?

If it is early in the course of the ingrown toenail, then home care may be successful in preventing the need for surgery.

  • Soak the foot in warm water four times a day. There is no need to add soap, Epsom salts, or antibacterial agents to the water.
  • Wash the foot, including the affected area, twice a day with soapy water. Keep the foot clean and dry during the rest of the day.
  • Do not wear high heels or tight-fitting shoes. Consider wearing sandals, if possible, until the condition clears up.
  • Try to lift up the corner of the nail that is digging into the skin. Take a small piece of cotton or gauze and roll it between the fingers to form a small roll or wick. Then place the roll between the nail and the skin to keep it elevated. This is painful but is the most important part of home treatment. After every soaking, try to push the roll a little farther in. Change the roll out every day. It may take from seven to 15 days for the nail to grow out so that it does not poke into the skin any longer.
  • A piece of dental floss can be threaded under the nail transversely under both sides and then glued to the edges of the nail and skin to keep it in place.
  • It's OK to take a pain reliever such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin).
  • If there is no improvement within three days, call a doctor.

What Are Ingrown Toenail Treatments?

If no acute infection is found, then the nail will be elevated and conservative treatment recommended. This consists of warm soaks, proper shoes, and frequent cleaning of the nail.

Sometimes, a doctor will choose to use a splint. Several types of splints can be used. These vary in type, but they all protect the skin from the sharp corner of the nail. Some of the most common types of splints include cotton wicks, plastic strips, plastic tubes down the side of the nail, and various glue-like substances (resins).

Occasionally, a doctor may try to file or cut the nail down the center in order to change the shape of the nail as it grows. A piece of hard plastic can also be glued to the nail to help it grow out flatter and in a straight line.

If any extra tissue has grown up around the inflamed area of skin, the doctor may choose to remove the extra tissue to help it heal faster. He or she will numb the area before removal of any tissue (resection).

Is Surgery Necessary for Ingrown Toenails?

If an infection is present, then surgical removal of either part of the nail or the whole nail and drainage of the abscess will be needed. This is performed in the doctor's office or in the emergency department. The extent of the procedure will depend on the severity of the infection, any other medical problems, and if this is a recurring problem.

How ingrown toenails are surgically removed

  • Sometimes a preoperative X-ray will be taken to make sure that the infection hasn't spread to the bone (osteomyelitis).
  • The doctor will inject a local anesthetic medicine.
  • The doctor will then drain the infection from the end of the toe or remove the extra tissue that has grown around the end of the nail.
  • At this point, the doctor will remove a portion of the nail (avulsion) so that the skin or infection can heal without the nail pushing on it.
  • The doctor may decide to destroy a portion of the nail matrix, the living tissue that produces the nail, by applying a chemical or by direct surgical destruction. This is performed so that the edge of the nail that caused the problem will not return, which is more likely with severe or recurring infections.
  • For very severe or recurrent cases that have already failed traditional surgery, a complete destruction of the nail matrix can be performed.
  • A lateral matricectomy is a procedure that surgically removes a portion of the nail bed and is usually performed by a specialist. It is considered the usual treatment for chronic or recurrent ingrown nails.
  • There are several newer types of surgery that don't alter the nail bed at all, instead they remove a portion of the soft tissue beside and/or underneath the nail in order to make more room for the nail to grow out. These types of surgery have shown promise but are not yet the standard of care, as they are still being studied. A flexible tube can also be slid along the side of the nail after removal of the extra tissue to help it heal properly.
  • Oral antibiotics are usually not prescribed for this problem because draining the abscess will take care of the infection.
  • The toe will then be covered with ointment and a gauze bandage.

What Follow-up Is Necessary After Surgery for an Ingrown Toenail?

  • Keep the dressing that the doctor applied on for two days.
  • On the second day, remove the dressing and wash with soap and water. Then apply triple antibiotic ointment (This is available at the drugstore.) and put on new gauze. Repeat this procedure twice a day until the wound has healed.
  • The doctor may want to recheck the wound in three to five days.
  • Take any antibiotics, if prescribed, as directed.
  • Keep the wound clean and dry. Follow any specific wound care instructions given by the doctor.
  • For the first three days, keep the foot propped up above the level of the heart as much as possible. This will aid in pain control.
  • If the doctor prescribed pain medicine, then take it as directed. Otherwise, acetaminophen (such as Tylenol) or ibuprofen (such as Motrin) may be used for pain control if there are no allergies to this medication.
  • Depending on the procedure performed, one can expect to be back on his or her feet in two days to two weeks, although it may take longer to return to athletic activity.

What Are Complications of Ingrown Toenails?

If the soft tissues of the toes become infected, then it is possible that cellulitis and perhaps even septicemia (bacterial infection in the bloodstream) could develop. This is especially true in those who have preexisting conditions like diabetes, AIDS, or any other condition that might compromise the immune response. In addition, constant pain produced by the ingrown nail could result in injury to other joints due to the need to change one's normal gait.

Is It Possible to Prevent Ingrown Toenails?

  • The best method of prevention is careful clipping of the toenails. Toenails should be clipped straight across -- taking care to keep the end longer than the skin edge. This prevents the corners from digging into the skin. They should not be rounded or cut too short.
  • Wear roomy, well-fitting shoes.
  • Keep the feet clean and dry.

What Is the Prognosis of Ingrown Toenails?

The toe usually heals well after this procedure. The primary concern is whether the nail will become ingrown again, which can occur even after destruction of the nail-growing cells.

The overall rate for recurrence of an ingrown toenail is 10%-34%.

If part of the toenail was removed, it will grow back within 12 months.

Ingrown Toenail Picture

Media file 1: The big toe shows redness and swelling of ingrown toenail.
Media file 1: The big toe shows redness and swelling of ingrown toenail.

Reviewed on 9/11/2017

REFERENCES:

Aksoy, B., et al. "Lateral Foldplasty with or without Partial Matricectomy for the Management of Ingrown Toenails." Dermatol Surg 35 (2009): 462-468.

Chapeskie, H., et al. "Soft-Tissue Nail Fold Excision: a Definitive Treatment for Ingrown Toenails." Can J Surg 53.4 (2010): 282-286.

Cordoba, D.D., et al. "Evidence of Efficacy of Alcohol Lavage in the Phenolization Treatment of Ingrown Toenails." J Eur Acad Dermatol Venereol 25.7 (2011): 794-798.

Di Chiacchio, Nilton, and Nilton Gioia Di Chiacchio. “Best Way to Treat an Ingrown Toenail.” Dermatol Clin 33 (2015): 277-282.

Erdogan, F.G., and G. Erdogan. "Long-Term Results of Nail Brace Application in Diabetic Patients with Ingrown Nails." Dermatol Surg 34 (2008): 84-87.

Farrelly, P.J., et al. "Comment on: Surgical Treatment of Ingrown Toenails in Children: What is Best Practice?" Ann R Coll Surg Engl 93.4 (2011): 336.

Heidelbaugh, J.J., et al. "Management of the Ingrown Toenail." Am Fam Physician 79.4 (2009): 303-308.

Li, J., et al. "Clinical Study of Treatment for Recalcitrant Ingrown Toenail by Partial Distal phalanx Removal." J Plast Reconstr Aesthet Sug 62.10 (2009): 1327-1330.

Majcen, M.E., et al. "Interpretation of Radiologic Abnormalities in Patients with Chronically Infected Ingrown Toenails with Regard to a Possible Exogenic Osteomyelitis." J Pediatr Surg 44.11 (2009): 2179-2183.

Matsumoto, K., et al. "Resin Splint as a New Conservative Treatment for Ingrown Toenails." J Med Invest 57.3-4 (2010): 321-325.

Mitchell, S., et al. "Surgical Treatment of Ingrown Toenails in Children: What is Best Practice?" Ann R Coll Surg Engl 93.2 (2011): 99-102.

Noel, B. "Surgical Treatment of Ingrown Toenail Without Matricectomy." Dermatol Surg 34 (2008): 79-83.

Peyvandi, H., et al. "Comparison of Two Surgical Methods (Winograd and Sleeve Method) in the Treatment of Ingrown Toenail." Dermatol Surg 37.3 (2011): 331-335.

Taheri, Arash, et al. "A Conservative Method to Gutter Splint Ingrown Toenails." JAMA Dermatology 150.12 December 2014: 1359-1360.

Tatlican, S., et al. "Chemical Matricectomy with 10% Sodium Hydroxide for the Treatment of Ingrown Toenails in people with Diabetes." Dermatol Surg 36.2 (2010): 219-222.

Vanhooteghem, O., et al. "Scedosporium apiospermum Septicemia Following a Wedge Excision of an Ingrown Toenail." Int J Dermatol 48.10 (2009): 1137-1139.

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