Ingrown Toenail: A small nail causing a big pain Introduction

Melissa C. Verde DPM and Mehul J. Shah DPM Larkin Community Hospital Miami, Florida

Who would believe one simple little toenail can limit your activities? If you suffer from an ingrown toenail, you understand just how painful it can be. The toenail can dig deep into the skin where the slightest pressure can aggravate the pain. You may have tried for hours to trim the toenail yourself, only to make it worse. This bathroom surgery is not recommended practice as it can lead to infection and permanent damage to the nail. To describe the proper ways of treating ingrown toenails, we must first explore the normal toenail and understand why it doesnt always grow correctly.

Healthy Toenails

Normal healthy nails appear clear where they are not adhered to the skin and pink where they are attached to the skin. The surface of the nail plate is smooth and thin (about one mm) with only a mild curvature at the sides. Nails are composed of a substance called keratin, similar to that in skin and hair, only harder because of less water content within the nail. They are a hard, resilient structure whose main function is to protect the blood vessels, nerves and bones underneath [1].

Toenails grow from an area, called the matrix, which lies underneath the cuticle. Any disturbance to this matrix may cause nails to grow abnormally; rather than being smooth and flat, they may project upward, grow with lines, grooves, pits, discoloration, or thickening [2]. Because the toenails grow slowly, about 0.05-mm/day, growing a new toenail can take 3 to 9 months [1].

Ingrown Toenails

Painful ingrown toenails can be the result of genetic over-curvature of the nail, overgrowth of the skin surrounding the nail (i.e., nail fold), or due to pressure against shoes, tight hosiery, or adjacent toes [3]. Injuries or infections can change the shape of the nail plate and additionally contribute to ingrown nails. Cutting the nail too short or cutting deeply into the corners of the nail can allow the nail to pinch the skin along the side as it grows. Often a spicule of nail is left when the nails are self-cut and this spicule becomes embedded in the skin. When walking, there is sometimes abnormal pressure along the side of the big toe pushing the skin up and around the side of the nailthis is especially true for those of you with flat feet. Toenail over-curvature may also be caused by a bony prominence beneath the nail (discussed in greater detail in the section Subungual Exostosis).

Signs and Symptoms

Ingrown toenails are often very painfulthe slightest pressure can aggravate the pain. The skin around the nail may appear red and inflamed. Eventually, a local infection may set inan infected ingrown nail is known as a paronychia. The toe will not only be red and inflamed; it may feel warm and have bloody or purulent (puss-containing) drainage. Some infections may also produce a foul odor. You would be surprised at how many people ignore this infection with hopes it will disappear in time. It wont! The affected portion of nail must be removed to resolve this infection.

Treatment

If the toe is not infected, soaking the foot in warm water will help soften the skin so that the invading nail or spicule can be removed. However, most people who try to fix the problem themselves (a.k.a. bathroom surgery) end up making it worse. The irritation and infection is resolved only by removal of the ingrown portion of nail and drainage of the abscess (swollen pocket of infected skin and puss).

After numbing your toe with a local anesthetic, your podiatrist will remove the offending portion of nail and clear away any infectious debris (figure 1 shown below). You will be advised to soak the toe in warm water and Epsom salt or diluted betadine twice a day for a week. Topical and/or oral antibiotics may be prescribed. If the infection has been present for a long time, an x-ray may be taken to ensure that the underlying bones of the toe are not affected.

Temporary or Permanent Procedure?

The only true cure for an ingrown nail is having the troublesome area removed either temporarily or permanently. If this is your first occurrence of an ingrown nail, your doctor will likely recommend a temporary removal and wait for the nail to grow outit may grow back normally. If however you suffer from chronic, long-standing ingrown toenails, one of several procedures can be performed to prevent that portion of nail from re-growing. A potential complication of permanent nail procedures is nail regrowth; no guarantees as to the permanent removal of your nail can be made. Permanent procedures may not be performed in the presence of infectionthis is at the discretion of your podiatrist and extent of infection.

Permanent procedures can be performed chemically or surgically. Both procedures require numbing of the toe and removing the offending portion of nail. Chemical destruction entails the implantation of a chemical that dissolves the nail matrix killing the nail root by chemical burn. The most commonly used chemicals are phenol and alcohol. This procedure is quick, safe, and relatively painless with few complications; the most common complication being a small burn of the skin surrounding the nail. A small amount of drainage from the area is normal, and soaking the foot twice a day will help keep the area clean. For partial nail avulsions, the result is a thinner nail that is much less likely to become ingrown. For complete nail avulsions, a firm layer of skin will take the former nails place.

Surgical correction of an ingrown nail may be preferred if your nail fold (the skin adjacent to the ingrown portion of nail) is hypertrophied (overgrown) and contributing to the painful symptoms. Along with the offending nail border, a section of the overgrown skin is removed with a scalpel. Sutures connecting the new skin margin with the nail bed are applied and left in for 10 to 14 days.

The foot should be kept dry until the sutures are removed. Pain medications may be prescribed for any discomfort during the recovery period, but severe pain is uncommon.

Prevention

If the problem is not due to genetic over-curvature of the nail, wearing shoes and hosiery that allow adequate room for the toes may prevent ingrown toenails. When trimming the toenails, be sure to cut them straight across with sharp instruments and file rough nail edgesdo not dig into the corners. If the problem is due to over-pronation (flatfoot) putting abnormal pressure along the outside of the toenail, your podiatrist can prescribe in-shoe devices called orthotics that can control your abnormal motion.

Subungual Exostosis

A subungual exostosis is a bony spur that grows off the tip of the bone lying underneath the toenail (sub- meaning below and -ungual meaning nail). This bony prominence arises in response to chronic irritation or injury, like dropping an object on the toe, and can be seen on x-ray. The overlying toenail is often thickened and malformed. The sides of the nail may curve inward and pinch the adjacent skin causing an ingrown toenail.

If wearing shoes with a heightened toe box does not relieve pain, surgery is indicated. Your doctor will decide if the toenail must be removed. A small incision is made at the tip of the toe and the bony spur is filed down. Your doctor may choose to do the procedure in the office or in a surgical center. Following surgery, you will have a couple of sutures that will be removed within 10 to 14 days. Pain medication will be prescribed as needed, but pain is usually minimal.

Other Nail Problems

Much like the eyes are the windows to the soul (how clich), your toenails can be the windows to more serious underlying disease. Yes, toenails give us insight to our overall health. Lines, brittleness, and discoloration can all indicate nutritional problems, reactions to medication, or systemic illnesses. These abnormalities may also be associated with a fungal infection of the nail itself. Alterations in the nail contour can be a normal variation or a result of heart or lung problems [3]. Pain in the tips of the toes may not be due to the toenails at all, but due to poor blood flow or nerve conduction. Consult your podiatrist for the best treatment course for your condition.

Conclusion

In order to keep us walking and enjoying physical activities, maintaining healthy feet is essential. This means wearing the proper type of shoes for work and play, wearing proper fitting shoes, performing good foot care and knowing when to see your foot specialist when problems arise. If you suffer from an ingrown toenail, consult your podiatrist for proper evaluation and treatment.

References

1.

McGlamry et al: Nails. Comprehensive Textbook of Foot Surgery 2nd edition., p.277-303; Williams and Wilkins Publishers, Baltimore, MD. 1992.

2.

Kligman, AM: Why do nails grow out instead of up? Arch of Dermatology. 84:313, 1961.

3.

Saur et al: Diseases Affecting the Nails. Manual of Skin Diseases 7th edition., p.285-290; Lippencott-Raven Publishers, Philadelphia, PA. 1996.