Received: 8 March 2016 | Revised: 12 May 2016 | Accepted: 6 June 2016

DOI 10.1111/dth.12392

THERAPEUTIC HOTLINE: LETTERS

Successful conservative treatment with cotton wisp for ingrown

toenail with granulation

Correspondence
Jun-Feng Du, Department of Plastic Surgery, Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
Email: idoctor@[Link]
or
Ze-Hu Liu, Department of Dermatology, Affiliated Third Hospital of Hangzhou, Anhui Medical University, West Lake Rd 38, Hangzhou, China.
Email: zehuliu@[Link]

Dear Editor, The patient was a healthy 34-year-old woman who had an
Ingrown nails are the most common inflammatory disease of the nail ingrown nail due to total traumatic avulsion of the toenail 25 years
unit. Classification of ingrown nails were developed and expanded as: before. She presented granulation and purulent discharge on the lateral
Stage 1 (inflammatory), Stage 2 (abscess), Stage 3 (granulation and nail folds of the right great toe with ache after improper trimming.
chronic nail fold hypertrophy), and Stage 4 (deformity of both nail folds Physical examination showed erythema, oedema in both lateral nail-
and distal fold) (Heifetz, 1937; Martinez-Nova, Sanchez-Rodriguez, & folds. Formation of granulation tissue and pus could be found (Figure 1).
Alonso-Pena, 2007; Mozena, 2002. Conservative management is rec- Staphylococcus aureus was recovered from the granulation. A diagnosis
ommended for Stage 1, while surgical measure and/or systemic treat- of Stage 3 ingrown nail was made. The patient refused surgical inter-
ment is considered for Stages 2, 3, and 4 (4). We used conservative vention, and asked for alternative treatment. Since many patients were
packing treatment with cotton wisp for ingrown toenail with granula-
tion successfully.

F I G U R E 1 Erythema, oedema in both lateral nailfolds with formation FIGURE 2 Cotton wisps under the ingrown nail edge with granulation
of granulation tissue shrink

Dermatologic Therapy 2016; 00-00 [Link]/journal/dth V

C 2016 Wiley Periodicals, Inc. | 1
2 | DU ET AL.

Martinez, and Dominguez-Cherit (2015) demonstrated that cotton

wisp with cyanoacrylate is an effective conservative method for Stages
1 and 2 ingrown toenails. Seven patients with ingrown toenail com-
plicated with granulation were successfully treated with a special
nail apparatus, and the granulation tissue was cauterized by silver
nitrate (Erdogan, 2006). There is no evidence to suggest that insert-
ing cotton wisp underneath an ingrown nail edge increases the risk
of infection (Heidelbaugh & Lee, 2009). Thus, daily packing with
cotton wisp can be done at home without repeated visits. To our
knowledge, this is the first case of Stage 3 ingrown toenail success-
fully treated by packing with cotton wisp. In our opinion, cotton
wisp, if properly applied, is the most simplest and effective means
for Stages 1 to 3 ingrown toenails.

AC KNOW LEDG EME NT S

We all contributed significantly to this work. We declare that we
have no conflicts of interest.

Dr. Jun-Feng Du1, Dr. Xiao-Yan Xi1, Dr. Ze-Hu Liu2

1
FIGURE 3 Square nail with granulation disappeared 4 weeks later Huazhong University of Science and Technology
2
Anhui Medical University
treated successfully by packing with cotton wisp in our clinic, conserva-
tive treatment approach was introduced. Patient education was con-
RE FE RE NCE S
ducted including the packing technique and principle, as well as
Erdogan, F. G. (2006). A simple, pain-free treatment for ingrown toenails
walking correctly, wearing appropriate footwear, and proper cutting complicated with granulation tissue. Dermatologic Surgery, 32: 1388–
the toenail square. The daily packing technique includes soaking the 1390.
foot in warm water, placing cotton wisps with mupirocin cream under Gutierrez-Mendoza, D., De Anda Juarez, M., Avalos, V. F., Martinez, G. R.,
the ingrown nail edge (FIG. 2) and lifting the foot bed rest. The ache & Dominguez-Cherit, J. (2015). Cotton nail cast: A simple solution for
relieved one day later, and the granulation tissue shrinked gradually mild and painful lateral and distal nail embedding. Dermatologic
Surgery, 41, 411–414.
and completely disappeared 4 weeks later (Figure 3). No recurrence
was observed over a follow-up of 3 years. Haneke, E. (2012). Controversies in the treatment of ingrown nails.
Dermatology Research and Practice, 2012, 783924.
Although ingrown toenail is often considered incapacitation and
Harrer, J., Schoffl, V., Hohenberger, W., & Schneider, I. (2005). Treatment
pain for the patient and lengthy periods off from work, it is often con-
of ingrown toenails using a new conservative method: A prospective
sidered trival. Ingrown toenail occur when the periungual skin is punc-
study comparing brace treatment with Emmert’s procedure. Journal
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body, inflammatory, infectious, and reparative processes (Harrer, Heidelbaugh, J. J., & Lee, H. (2009). Management of the ingrown toenail.
Schoffl, Hohenberger, & Schneider, 2005). Conservative and surgical American Family Physician, 79, 303–308.
treatment options exist and should be presented to the patient Heifetz, C. J. (1937). Ingrown toe-nail. A clinical study. The American
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associated with high recurrence rate on the order of 70%. The use of
Mozena, J.D. (2002). The Mozena Classification System and treatment
cotton wisp, stretching the soft tissue away from the side of nail, is
algorithm for ingrown hallux nails. Journal of the American Podiatric
one of the simplest, most effective and eldest means of conservative Medical Association, 92, 131–135.
treatment for ingrown toenails (Haneke, 2012; Heifetz, 1937; Senapati, Senapati, A. (1986). Conservative outpatient management of ingrowing
1986). Recently, Gutierrez-Mendoza, De Anda Juarez, Avalos, toenails. Journal of the Royal Society of Medicine, 79, 339–340.