# Ingrown Toenail Management

## Overview

This module describes two conservative and one surgical treatment option for ingrown toenails.

## Indications

1. Ingrown toenails

## Contraindications

1. Surgical management contraindicated in:

   - Peripheral vascular disease
   - Coagulopathy

2. Use of phenol contraindicated in pregnancy

3. Chemical matrixectomy contraindicated in:

   - Uncontrolled diabetes
   - Peripheral vascular disease

## Patient information and consent

### How do I explain this procedure?

“Your toenail has become ingrown, which means that the corner or side of the toenail is pressing and cutting into the skin beside it, causing pain and putting you at risk of getting an infection. I will try to release the ingrown part, and if that does not work I may need to cut it out.”

### What can my patient expect?

“I will give you an injection for pain. If the ingrowing is not too severe, I will just put cotton or a small piece of plastic between the toenail and your skin to prevent it from progressing. If it’s severe or it keeps on happening, I will cut out a section of your toenail and destroy the part that makes the nail grow out there so that it won’t happen again. If I’ve cut away part of the nail, expect the wound to ooze a bit of clear fluid for a few weeks until it dries out.”

### What is my patient’s role?

“Let me know if you have any allergies or a bleeding tendency, use blood thinners, or have any medical conditions. Fearing blood or needles is normal, but tell me if you have fainted from it. Once we’re done, you’ll have to change the dressing in two days, and keep checking for signs of infection, like increasing redness, heat, swelling and pus.”

## Preparation

### Documentation

1. Patient notes

### Equipment

Conservative management:

1. Non-sterile gloves

2. Alcohol-based hand rub

3. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

4. IV giving set

5. Cotton wool

6. Alcohol swab

7. Suture pack

   1. Dental syringe
   2. Scissors

8. Lignocaine

9. Dental needle

Surgical management:

1. Non-sterile &

   sterile gloves
   sterile gloves

   Although it is considered best practice to use sterile gloves to perform minor procedures, there is mounting evidence that infection rates are similar for sterile and non-sterile glove use.

2. Alcohol-based hand rub

3. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

4. Linen saver

5. Skin disinfectant
   Skin disinfectant

   Commonly used preparations include 0.5-2% chlorhexidine in 70% alcohol (Steriprep), or 10% povidone iodine. There is no consensus on the superiority of one agent above another. Caution: chlorhexidine solutions may be associated with burns and skin breakdown in infants < 2 months old.

6. Tourniquet

7. Sterile drapes

8. Suture pack

9. Lignocaine
   Lignocaine

   It is current best practice to avoid the use of adrenaline in the penis and digits due to concerns of ischaemia; however, this seems to be controversial in the literature.

10. Alcohol swab

11. Dental needle

12. 80-88% phenol solution

13. 10 ml syringe of normal saline

14. Cotton-tipped applicator

15. Paraffin-impregnated gauze (Jelonet), gauze, and a crêpe bandage

## Site & Positioning

Position the patient reclining with the knee bent and the foot flat on the bed.

## Procedure

### Conservative management

Follow medical asepsis with non-sterile gloves.

1. Perform hand hygiene and don non-sterile gloves.

2. Open the suture pack.

3. Clean the skin with an alcohol swab and perform a digital block. Wait 5-10 minutes.

4. Use one of the following techniques:

   - Create a wisp of cotton wool and wedge it under the corner of the ingrown nail. Use see-saw movements to advance it under the nailfold until it splints the entire lateral/medial edge of the nail away from the affected nail fold, OR
   - Gutter splint: cut a section of an IV giving set as long as the affected medial/lateral nail fold. Cut it open lengthways. Slip the long edge under the entire affected nail edge to separate it from the affected medial/lateral nail fold.

### Surgical management

Follow medical asepsis with sterile gloves.

1. Perform hand hygiene.

2. Open the suture pack to create a sterile field. Pour skin disinfectant into the bowl. Use spare gauze to remove the dental syringe from the field.

3. Don non-sterile gloves, clean the skin with an alcohol swab and perform a digital block. Wait 5-10 minutes.

4. Don sterile gloves.

5. Clean and drape the toe.

6. Apply a tourniquet made of rubber tubing or a glove, around the base of the toe to reduce bleeding. Secure the tourniquet with forceps.

7. Use a haemostat to separate the affected side of the nail plate from the nailbed and affected nail fold down to the cuticle. You can do this by placing the haemostat between the nail and the nail bed and between the cuticle and the nail fold and working it loose.

8. Use scissors to

   cut
   cut

   a section of the nail plate (about 3-5 mm wide) in a straight line down to the cuticle. Extend the cut below the proximal nail fold to include the root of the nail. Do not cut the cuticle or skin of the nailfold.

9. Remove the slice
   Remove the slice

   by rotating it with forceps, ensuring that you also remove the root.

10. Use a haemostat to explore the proximal nail fold for retained nail fragments.

11. Use phenol on a cotton-tipped applicator (or the back of the applicator) to

    ablate
    ablate

    Be careful not to allow the phenol to touch the normal skin. You can do this by applying vaseline to the normal skin first.

    the matrix under the nail fold with three applications of 30 seconds each.

12. Rinse away phenol with a syringe of saline or a cotton wool bud soaked in saline.

13. Remove the tourniquet.

14. Dress with paraffin-impregnated gauze, dry gauze, and a bandage.

15. Dispose of medical waste safely.

16. Record completion of the procedure in patient notes.

## Troubleshooting

My patient has returned with an infection.

Treat the patient with a course of oral antibiotics covering skin flora.

I don’t have phenol available.

Without ablation of the matrix, the ingrown toenail is likely to recur. You may use silver nitrate sticks, but warn the patient that it might cause tattooing of the area. Alternatively, an experienced provider may excise the matrix mechanically, although this is an inferior treatment to chemical ablation and requires cautery, an assistant, and should preferably be done in theatre.

My patient has returned with a recurring ingrown nail despite ablation of the matrix.

Refer this patient to surgery for more radical management.

## Risks

1. Minor bleeding

2. Poor cosmetic outcome

3. Local infection

4. Nail regrowth

5. Inclusion cyst
   Inclusion cyst

   This may be formed when epidermal cells remain the dermal layer.

6. Healthcare provider exposure to infectious material

## References

1. Mayeaux EJ Jr, Carter C, Murphy TE. Ingrown Toenail Management. Am Fam Physician. 2019;100(3):158-164.

2. Chabchoub I, Litaiem N. Ingrown Toenails. [Updated 2021 Jun 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546697/

3. Streitz MJ. How To Treat an Ingrown Toenail. In: MSD Manual. 2020.

4. Mash B. How to Remove an Ingrowing Toenail. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010:167.