Controversies in the treatment of ingrown nails

Abstract

Ingrown toenails are one of the most frequent nail disorders of young persons. They may negatively influence daily activities, cause discomfort and pain. Since more than 1000 years, many different treatments have been proposed. Today, conservative and surgical methods are available, which, when carried out with expertise, are able to cure the disease. Packing, taping, gutter treatment, and nail braces are options for relatively mild cases whereas surgery is exclusively done by physicians. Phenolisation of the lateral matrix horn is now the safest, simplest, and most commonly performed method with the lowest recurrence rate. Wedge excisions can no longer be recommended.

Figure 1

Schematic illustration of the adolescent type of ingrown nail. (a) Oblique view. (b) Dorsal view.

Figure 2

Laterally ingrown nail with granulation tissue in a 15-year-old male patient.

Figure 3

Pincer nails in a 56-year-old female patient. (a) Frontal view. (b) Dorsal view. (c) X-ray dorsal view of the distal phalanges shows the lateral deviation of the terminal phalanges and the medial hook-like exostoses at the base of the bone. (d) X-ray lateral view demonstrates the distal dorsal traction osteophyte.

Figure 4

Neonatal ingrown nails.

Figure 5

Schematic illustration of taping.

Figure 6

Schematic illustration of packing.

Figure 7

Schematic illustration of gutter treatment.

Figure 8

Schematic illustration how wedge excisions are most commonly performed; the wedge is very wide in the middle of the lateral nail fold, but the lateral matrix horn is not completely excised. (a) Transverse section at the level of the midnail bed, (b) transverse section at the level of the matrix horns.

Figure 9

Toenails of a 38-year-old female patient 16 years after bilateral wedge excisions for ingrown nails showing onychogryphosis and malalignment. (a) Right foot, (b) Left foot.

Figure 10

16-year-old boy 4 years after a wedge excision, which had been complicated by infection and necrosis of the lateral nail fold. There is considerable malalignment to the side of the necrosis.

Figure 11

Schematic illustration of the reduction of a hypertrophic lateral nail fold by a fusiform excision.

Figure 12

Schematic illustration of the selective lateral matrix horn resection.

Figure 13

Proximal lateral and medial nail portions corresponding to the lateral matrix horns. The lateral nail strips have been separated from the nail bed, and the most proximal-lateral corners of the nail are elevated to show its true shape. As they are markedly curved downwards, the matrix horns are expected to reach deep plantarly and proximally.

Figure 14

Schematic illustration of lateral matrix horn phenolisation. The ingrown strip of nail plate is avulsed, and a cotton tip applicator dipped into liquefied phenol is vigorously rubbed into the matrix horn under the proximal nail fold for 2 to 3 minutes.

Figure 15

Phenolisation of the lateral matrix horn. (a) The lateral nail strips are avulsed and shown. (b) Phenol is rubbed into the lateral matrix horn. (c) At the end of surgery, small antibiotic tablets are put into the wound cavity.