Ingrowing
toe nail : conservative treatment
.........................................................................................................................
Dr.
Waleed Haddaden, MD, MRCSI
Department of General
Surgery, Royal Medical Services, Jordan
Correspondence:
Dr Waleed Haddadin
TEL NO. 0777981229.
Email: manolee74@gmail.com
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ABSTRACT
Objective: Ingrowing toe nail is
a common problem that the surgeon faces
in their practice, especially the surgical
doctors in the army. The objective of
our study is to evaluate conservative
treatment in dealing with ingrowing toenails.
Methods: Data were collected prospectively
from patients who presented to our surgical
clinic in Prince Hashim hospital in Zarqa
between January 2007 and September 2007.
152 patients presented with ingrowing
toe nail. They were classified according
to the Hriftiz classification into three
stages. 90 patients were diagnosed to
have stage III disease. Surgery was offered
to them immediately and they were excluded
from our study. 27 patients had stage
I disease and 35 patients had stage II
diseas e, so both groups were initially
offered conservative treatment, by elevating
the corner of the nail by a small piece
of cotton wool and were followed up over
a mean period of 10 weeks.
Results:
Of those who were treated conservatively,
stage I patients had a response rate of
96.2% (26 of the patients) , and stage
II had a response rate of 94.2% (33 of
the patients), with a mean recovery period
of 5.5 weeks.
Conclusion:
Conservative treatment is a worthy trial
for patients with ingrowing toe nail especially
in the early stages of the disease and
should be offered to the patient, although
it needs a highly cooperative patient.
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Unguis incarnates, onychocryptosis
or ingrowing toenail is a common disease and
causes considerable pain and discomfort with
functional consequences(1). It has different
causes with the most common cause poor cutting
of the nail. Other causes include abnormal curved
nail, tight shoe wearing and previous trauma
to the nail that has changed its shape. Pain
is the main symptom of ingrowing toenail. If
it becomes infected it may drain pus(2). It
is divided into three stages, according to the
Heifitz classification(3) (Table 1). Many invasive
approaches have evolved for ingrowing toenail
such as classical wedge excision and lateral
matricectomy, either by debridement, phenol
or electrocautery ablation, but these surgical
therapeutic modalities have had many disadvantages
such as prolonged wound healing period, scarred
and deformed nail production or restriction
of normal activities. In recent years, non-invasive
techniques have evolved as feasible treatments,
challenging the more traditional surgical treatments.
Elevation of the nail fold by a small piece
of cotton wool packed under the free edge of
the nail is a simple non-invasive therapeutic
method that is easy to perform and dose not
require any special equipment(4) . In this study,
effectiveness of nail elevation is evaluated
and re-assessed as a classical therapy for patients
with onychocryptosis.
| Heifitz
Classification |
| I Pain with mild
erythema and swelling of the nail fold. |
| II Increased swelling,
seropurulent discharge and laceration of
the fold. |
| III Chronic inflammation
with granulation and marked fold hypertrophy. |
Table 1
Stage I Ingrowing toe nail
Stage II Ingrowing toe nail
Stage III Ingrowing toe nail
A prospective study on the nail elevation technique
was conducted on the patients who presented to
the outpatient clinic in Prince Hasham Hospital
in Zarqa between January 2007 and September 2007.
152 patients who presented with an ingrowing toenail,
were classified into 3 stages. 90 were diagnosed
to have stage III. Of these 7 had a previous surgery
and 3 were diabetics so surgery was offered to
them immediately and they were excluded from our
study. 62 patients (55 male and 7 female) with
a mean age of 29, who had stage I or stage II
disease and approved of our technique, were studied
with regular follow up. All patients were examined
and followed by the authors. All patients were
instructed to wear loose-fitting shoes or sandals
whenever possible. The nail was cut straight leaving
the corners untrimmed. The tingrowimg toe nail
was then elevated with a small piece of cotton
wool packed under the free corner of the nail,
applied with a pair of sharp forceps in the out
patient clinic. Patients were instructed to repeat
the cotton wool insertion when necessary. Patients
were seen once weekly for two weeks then once
every two weeks. Patienta were instructed to keep
the cotton wool piece in place until there were
no symptoms in the area including pain, swelling,
erythema and exudation (a mean of 70 days in this
study). None of the patients received oral antibiotics
throughout that period(5).
|
Demographic
data
|
|
Number
of patients
|
62
|
|
Mean
age
|
36
years
|
|
Males
|
55
patients
|
|
Mean
follow up time
|
70
days
|
|
Table 2
152 patients presented to our outpatient clinic.
27 presented with stage I and 35 with stage
II, and 90 patients presented with stage III,
who were offered surgery immediately and excluded
from the study. 62 ingrowing toenails were offered
conservative treatment. The mean duration of
symptoms were 2 weeks in stage I and 3 weeks
in stage II. The mean age of the subjects was
36, (55 males and 7 females). The site of the
ingrowing toe nail was the first tarsal for
all the cases. Patients were followed for a
mean of 10 weeks. Of the cases who presented
with stage I, all were cured within 4 weeks,
and only one case had recurrence, and was treated
successfully by wedge resection of the nail.
The cases with stage II were cured within 6
weeks. Only 3 had recurrence. One of them was
treated by the same method and the other two
insisted on surgery and were treated and cured
by a wedge resection of the nail.
|
Results
|
| No.
of patients with stage 1 |
27
(43.5%) |
| No.
of patients with stage 2 |
35
(56.5%) |
| Recurrence
in stage 1 patients |
1
(3.7%) |
| Recurrence
in stage 2 patients |
3
(8.6%) |
| Cure
of stage 1 |
4
weeks |
| Cure
of stage 2 |
6
weeks |
|
Table 3
Before treatment
After treatment
In the past, nail avulsion, wedge resection,
total matrix ablation, and other surgical treatments
of ingrowing toenails have been associated with
high recurrence rates, considerable postoperative
pain and poor cosmetic result. More recent studies
have shown that with segmental matrix excision,
segmental phenolization and wedge resection
in combination with segmental phenolization,
far more acceptable results can be achieved.
These simple methods were first described by
Heister in 1763. For the result of conservative
treatment, most authors have referred to the
article by LIoyd-Davies and Brill published
in 1963. These authors treated 100 conservative
patients in their toe clinic by warm soaking,
cotton wool packing beneath the nail and in
the nail grooves, removing the granulations
by silver nitrate applications and extensive
hygiene instruction. According to this article,
33% of the patients were discharged as cured
after 2 years, and 27% were still under treatment.
40% had defaulted(6). However, a success rate
of 74% for conservative management has been
reported even in advanced cases, although follow
up has only amounted to 6 months. Another study
using the same method was published in 1986
with a success rate of 79%.
Our study shows that conservative treatment
of ingrowing toenail is simple but time consuming.
It requires a degree of co-operation from the
patient and perseverance on the part of the
doctor, and the cosmetic result, post treatment
pain, and the time to return to normal activities
are acceptable.
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non-operative and operative care. Clin Ortho
Relat Res 1979; (142): 96-102.
2. H.J.Pearson. R.N.Bury. J. Wapples. D.F.L.Watkin.Ingrowing
toenails: Is there a nail abnormality. The
journal of bone and joint surgery Nov, 1987
Vol. 69-B, No 5.
3. Persichetti, Paolo MD, PhD; Simone, Pierfranco
MD; Li Vecchi, Giancarlo MD; Di Lella, Filippo
MD; Cagli, Barbara MD; Marangi, Giovanni Francesco
MD. Wedge excision of the nail fold in the
treatment of ingrown toenail. Annals of plastic
surgery. June 2004 Vol 52(6):617-620,.
4. Asha Senapati. Conservative outpatient
management of ingrowing toenails. Journal
of the royal society of medicine. June 1986;
Volume 79.
5. A. M. C.Bos,M .W. A. van Tilburg, A. A.
van Sorge and J. H. G. Klinkenbijl. Randomized
clinical trial of surgical technique and local
antibiotics for ingrowing toenail. British
journal of surgery 2007; 94:292-296.
6. LIoyd-Davies RW, Brill GC. The aetiology
and out-patient management of ingrowing toe-nails.
British journal of surgery 1963; 50:592-7.
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