Most ingrown nail infections
can be described as a simple foreign body reaction. The nail grows into
the skin and acts as a foreign body, just like a splinter or a piece of glass.
Continued pressure by the nail against the skin causes inflammation and a soft
tissue infection.
The most common reason we develop ingrown
nails is due to improper trimming of the nail. The nail is very weak when
twisted (torsion). If the nail is trimmed so that a small spur, called a spicule, is left on the border of the nail, the nail
will continue to grow forcing the spicule into the skin. As the skin
responds to this 'foreign object' it becomes inflamed and sore. The area
adjacent to the nail will become increasingly more difficult to trim, and so
begins the vicious cycle that we call an ingrown nail.
The majority of ingrown nails are on the hallux
(big toe). Pain is usually tolerable until the nail is bumped or stepped
on. Ingrown nails are extremely common in adolescent boys and in women 2-3 months
postpartum. Why? Young boys seem to have little regard for regular hygiene and
pregnant women have a difficult time reaching their feet during the last several
months of their pregnancy, not to mention the additional burden of their feet
swelling.
The shape of the nail can also be a contributing
factor for ingrown nails. Pincer nails( as shown to
the left), a term used for nails that have a
pinched appearance, put pressure on the periungual folds. As
shoe pressure is exerted on the nail, the edges of the nail push into the skin
just as the weight of something put on a table pushes through the legs of the
table to the floor.
Other contributing factors that may cause ingrown
nails include trauma to the nail, pressure from adjacent
toes and the shape or profile of the forefoot in relationship to the shape of
the toe box of the shoe. Medical conditions, such as fungal infections or
psoriasis, can change the shape of the nail and contribute to ingrown nails.
Treatment for ingrown nails
Ingrown toenails are treated much the same as a splinter.
Antibiotics and soaking can help to reduce the inflammation associated with the
ingrown nail, but until the foreign object (ingrown nail) is removed, the stale
mate between the nail and adjacent skin will continue. Removal of the
offending border of nail is necessary in most cases of ingrown nails.
Many have suggested the 'proper' way to trim the
nail, but in actuality, every nail is a bit different from the next nail.
Therefore, it's most important to trim the nail with
quality nail trimmers in a way that it is not going to
irritate the periungual fold. Trimming the nail straight across may work
for some but is ineffective for others. Some advocate cutting a groove or
V in the distal tip of the nail. This is also ineffective. Cotton under
the edge of the nail has been tried, even metallic clips that 'lift' the nail,
but each of these will fail in time unless the offending border of the nail is
removed. NailEase may
help to lift the edges of the nail in a limited number of cases. Many pregnant
women develop ingrown nails due to their inability to reach their feet. NailEase
is a great product for them since they are poor surgical candidates until they
deliver.
The technique used most commonly today to treat
infected ingrown nails is called a phenol-alcohol procedure (P&A procedure). This
procedure is performed in the office under a local anesthetic on
an out-patient basis. After the toe is numbed and cleaned with a
disinfecting agent, a thin margin of nail is removed. Phenol, which is 77%
carboxylic acid, is applied to the nail matrix to kill the cells that produce
that small margin of nail only. The phenol is then flushed out with
alcohol. Patients can return to a Band-Aid and regular shoes the next day.
The interesting thing about the phenol-alcohol
procedure is the lack of pain experienced by patients following their
surgery. This is due to the fact that phenol has a topical anesthetic
property that last for 2-3 weeks. Although the procedure will drain for
several days, the benefit of using phenol is significant. Phenol is best
know as the active ingredient in Chloroseptic Mouthwash Spray. In
Chloroseptic, phenol is used in a more dilute concentration but has the same
effect in that it inhibits sore throat pain.
Other surgical procedures may be used with or
without phenol and include the use of a CO2 laser or other chemicals to destroy
the matrix cells. The decision to remove one border, both borders or the
entire nail should be discussed with your doctor.
The following images show the steps involved in correcting an
ingrown nail with a P&A or phenol alcohol procedure. Image 1 shows
administration of local anesthesia. Once the nail has been anesthetised,
the foot is prepped with a Betadine or comparable solution. Image 2
shows a small tourniquet (Penrose drain) around the toe to inhibit bleeding (hemostasis).
A nail splitter is being used to create a clean split to remove just the borders
of the nail. Image 3 shows a hemostat being used to remove the nail.
The nail bed is then scraped with a small curette to physically destroy the nail
matrix. In image 4 we see the application of phenol. Phenol
application is normally done 3 times for 5-10 seconds each application.
And image 5 shows the final bandage. This procedure is completed in 10
minutes and is performed in an office setting. Post-op care varies, but
steps are taken to promote drainage of the nail and may include Epsom Salt soaks
or application of steroid/antibiotic drops. Patients return to a normal
shoe the day after surgery wearing just a 1 inch Band-Aid. Healing takes
10-14 days.
