Perhaps the most common condition seen in a podiatrist’s office is the ingrown toenail. In my practice, I have noticed this to occur most commonly in younger men but certainly there is a wide distribution of patient’s suffering from this condition. It is not as common to see this in the elderly.
Recalling that Androcles pulled a thorn from the lion’s paw illustrates how something as small as a thorn has the ability to incapacitate even the strongest and toughest. And while not quite a podiatrist and not quite an ingrown nail, the story’s point is made.
At the base of a nail are the cells that form the eventual nail. The toenail has a width just as your toe, itself, has margins in which the nail should grow. In many cases, the cause of ingrown nails is directly related to the manner in which the nail is cut. As the nail is cut, many patients are overly aggressive and cut the nail on an angle that allows the distal margin of the toe to fold in slightly. When the nail grows out, it bumps into the nail fold which becomes inflamed and uncomfortable. Of course trauma and some irregularities of the cellular configuration are not uncommon causes that contribute to this condition.
At this point I would like to make the distinction between an ingrowing nail and an ingrown nail. An in ingrowing nail, connoting an action in progress, is a sub-acute but sore area of the toe where the nail is pressing on the skin fold. The toe hurts more when pressure is applied but otherwise, doesn’t feel too bad unless something hits it. There is redness and localized tenderness all associated with inflammation. In contrast, an ingrown nail is one in which the nail has broken the soft tissue of the skin fold and is often accompanied by drainage, warmth, increased pain, with or without pressure and a localized and sometimes systemic infection.
When presented with the mildly tender ingrowing nail, it is often easy enough to cut the nail back just proximal to the point of tenderness, being sure to round the edges of the remaining nail edge. Most often, there is near complete relief after the nail section has been removed. I often recommend warm saline soaks and the application of vasoline or Neosporin in the groove that remained.
Generally speaking, an ingrown nail is too tender to remove without the benefit of a local anesthetic. Once the toe is numb, a vertical section of the nail is removed whereby enough of the underlying wound is free of pressure and the full wound margins are visible. It is important that the wound has enough time to heal before the new nail grows back over it. Again, warm, saline soaks are recommended and a light dressing is applied as needed.
The place for antibiotics with these wounds should be on per patient basis. Many patients have been placed on drugs before I ever see them. They relate improvement while on the medication but recurrence after they have stopped. The key here is not the antibiotics but the removal of the offending nail. The nail, itself, acts as portal of entry for bacteria directly into the wound. Until the nail is removed, the wound is prone to reinfection.
When there is recurrence of an ingrown nail, a permanent procedure to selectively eliminate the margin of the offending nail can be performed in the office. It is performed under a local anesthetic and only requires about 15 minutes. The post-operative course is relatively short and the success rate approaches 100%.
As common as the ingrown nail is, avoidance of it seems relatively simple. You must use the appropriate instruments, avoid vertical cutting of the nail and round all nail edges.
Andrew E Schwartz, D.P.M.
51 Hospital Hill Road
Sharon, CT 06069
860 364 5944
88 Elm Street
Winsted, CT 06098
860 379 3100