Ingrown Toenails 101

When you get an ingrown toenail it can really be painful, to a point where even the bed sheets can be painful when placed on the toe.

This is a very common condition that affects all ages, from babies to the elderly, no one is immune.

Teenage boys and teens are prime age for this condition. The main reasons why are:

  • excessive sweating
  • poor hygiene
  • sports
  • poor nail cutting
  • a thin nail and
  • rapid nail growth.

The skin becomes damp and macerated and with increased sport and rapid growth, the nail works its way into the skin. Mid to the lower portion of the side of the nail, and usually both sides of the nail.

What exactly is an ingrown toenail? It is where the nail is excessive, natural or mechanically altered to cause pain resonating from the sulci (side skin of the nail)…a lot of words 🙂

I have split this condition up into 2 sections. Pseudo and True.

Most patients believe they have an ingrown nail because of poor nail cutting but that is not always true and usually, re-education is needed to reassure the patient and to explain that this could be a reoccurring problem.

Many clinicians do not state this and this leads to the patients believing the clinician caused the problem or failed to fix their problem.

Pseudo nails are not really ingrown toenails, but with the above definition, fall into that category.

The main culprits are involuted and wide nails. Sometimes you find that a nail is just too wide for the toe. As the nail grows, it jostles for position through the toe and any mild amounts of trauma can cause a problem. Unfortunately this type of nail is hard to maintain because you will note that the actual redness and pain radiates from the middle part of the sulci (sides of the toe- where the nail meets the skin) all the way down to the eponicium (base of the nail).

ingrown toenail cause #1 Involuted nail

involuted nail ingrown toenail
Here is an involuted nail (sometimes called a pincer nail. The picture is quite severe). However the nail is hard to cut and could be uncomfortable, but notice that the skin hasn’t been broken.

ingrown toenail cause # 2 Wide nail

ingrown toenail wide nail
If some patients have venous problems or are quite large that also causes swelling, overlapping of the skin causes an ingrown toenail. This is where you have a normal nail but because the toe itself grows and overlaps the area to which the nail grows reduces causing ingrown toenails. This is very similar to nails that are too wide for the toe itself.

Some people also think that there is too much skin- in this case, the sulci skin is removed without touching the nail. Too wide nail? Too much skin? I prefer the too wide-nail idea.

ingrown toenail cause #3 poor nail cutting/ trauma

ingrown toenail poor nail cutting
Then you have the traditional toenail that has been cut poorly and a small spike of the nail is left, as seen in the picture.

Just by looking at this nail, you can easily see that a spike is present…if you go up from the purple cross you can see very slight whiter skin around the scab- which means that a spike is pushing up under the skin.

The signs of an ingrown toenail

1. A lump on the side of the nail. This is where the war is going on. The body is fighting off bacteria and nails that are present. However, it can not attack the nail, so as the nail grows it presses more into the skin, causing more swelling…and the cycle continues.

2. It can be painful to the touch especially if there is a spike. What you are doing is basically pressing the spike into the skin which causes pain.

3. Bleeding can be more prominent because of the very vascular nature of the bump on the side of the nail.

4. Smell. The area, after some time, can start to smell. This is because dead blood, white cells, and bacteria are building up. Usually, antibiotics take care of the infection, but they will not take care of the nail. We have seen patients on antibiotics for some weeks with the Doctor’s failure to refer on to get the nail sorted out.

5. It sticks to socks…because of the discharge and fluid that is being released. When you rip off your socks you irritate the area even more.

Treatment for Ingrown Toenails

Treatment for Ingrown Toenails depends upon 2 things.

1. Where the problem is and,

2. How long they have had the problem.

For a problem like this, I would go and see a Podiatrist/ Chiropodist.

Many home treatments fail to do anything and can even make the problem much worse.

I am active in the Yahoo Answers Community. Here is someone who posted a question and did a search online for help:

———–

Swollen big toe-ingrown/hangnail? So last week sometimes i clipped a piece of flesh/nail from the corner my big toe (right foot if it matters). i noticed a little stinging for a few days but it wasn’t until yesterday that it actually began to swell and turn dark around the cuticle. I goggle and self diagnosed a ingrown /hangnail, so i did the epsom salt soak then doused with peroxide and applied some triple antibiotic ointment. My problem now is that since i’ve done all that this evening, its actually gotten a bit more painful and swollen a little more. there is no pus draining its just the pain and discoloration. should i continue the epsom salt until at least weekend or just suck it up and go to the doctor now?

———–

The problem comes in the fact that peroxide, Epsom salts, and ointments are going to do more damage. They will make the area very wet and make the nail dig in further and get infection to go into moist tissue.

For the majority of patients, conservative treatment methods for ingrown toenails are needed from a clinic. If the problem occurs from the tip to a quarter of the way down the sulci, then small nippers should easily remove the offending nail with minimal discomfort to the patient. The clinician would then use a Blacks file to smooth the edge of any rough edges. It is a relatively painless 5-minute procedure.

If you have had one ingrown toenail, and that is the one you are treating, then Nail Surgery is not really advised, mainly because it is overkill- there is no need unless the nail is too bad to work on conservatively.

Usually, the toe, once the spike has been taken out, will reduce itself to its original size and the inflammatory reaction will reduce. Just like taking a splinter out of your skin, once it has been done, the site heals itself up without a problem.

Home Treatments

There are no home treatments that can effectively take out ingrown toenails without making the problem worse:

1. Use saltwater. Only use it for 3 mins max and then dress the area with a clean dressing that covers the whole area. Saltwater bathes daily and changes the dressing at the same time. This will keep down infection until you get to see someone. If you need to have a shower/ bath then keep your dressing on when you do bathe, but do the redressing routine when you come out.

2. Always place a sterile dressing over the affected area- never put tape on the area because it will stick and cause pain. Change this daily.

3. Does cutting a “V” shaped section out of the nail help? No. There is nothing to suggest, or even proven that it eases pressure, all it will do is cause holes in hosiery and socks.

4. Some people favor inserting cotton wool down the sides of the sulci to relieve the pressure and some people have noted success with this type of treatment. I have reservations about sticking anything foreign down the sulci. I believe that people forget about the cotton wool and now you have debris that will not degrade and will become compact over time causing extra pressure and problems. I believe that this is a poor treatment option that has been around for a long time so it seems like it is “standard treatment practice”.

5. Another treatment option is the application of a brace to the nail that lifts up the sides of the ingrown toenail. This is a similar technique to the cotton wool idea, but the brace is attached over the nail and can be checked and removed after a month of wearing the brace. Many people have reported success, but again I have doubts about the long-term use of such a device. A brace adds more pressure to the skin especially when they are solid objects so the choice of patient needs to be considered. The use of the brace means that the patient needs to revisit in one month of application to see if there is any difference.

Unfortunately, adherence is a problem and it is likely that the brace will be tampered with especially if it is left on for long periods of time. Also, it is a nail growth problem, once the brace has been removed is the nail going to be ingrown-free? Probably not.

More Severe Ingrown Toenails

This is where it gets slightly gray.

The best, simplest and easiest treatment for severe or reoccurring ingrown toenails is the use of minor surgery. Now many clinicians have different methods and different ways of doing this simple procedure, unfortunately, they can mess it up for everybody as well.

What we do is the following:

1. Assess the patient, making sure that they know what is happening, they want it done and other treatment options have been discussed.

2. Inject the toe with a local anesthetic, this does sting a bit but then the whole toe goes numb. You will be able to feel tugging but no pain, in done right.

3. We test the toe- make sure you can not feel anything, if you can we might wait longer (takes 10 mins to kick in) or give you more- into an area where you can’t feel.

4. We then begin, and using specialized nail clippers we clip the offending part of the nail away. If it is for the sides of the nail we take both sides out forces push over and will cause an ingrown nail on the other side if not done, also it looks better. If removal of the whole nail, we remove the nail.

5. Any removal of the nail comes with it the matrix- where the nail grows from. Any left behind will start the whole process again.

6. We then apply Phenol to the area where the matrix comes from. This stops the nail from growing back 97% of the time. In certain circumstances, we would not use Phenol as we want the nail to grow back.

7. We dress the area and make sure the patient is OK, and then we see them back the next day and then every week after that, giving instructions on how to take care of the toe.

In all of this the patient has not had their skin cut, can walk in and out of the clinic and the procedure itself took 8 minutes. In all the body takes 4-6 weeks to heal the toe. It’s because of the Phenol that it takes so long, but you walk out pain-free 😉

If you go to the hospital, sometimes they surgically cut the matrix away which increases healing time, and many times the nail grows back because they haven’t got all of it.

All in all, it depends upon the site of the ingrown toenails if there is an infection, and how long you have had it to decide what needs to be done.

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