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Monthly Archives: March 2012

Causes and Treatment of Ingrown Toenails

Onychocrptosis, also known as ingrown toenail is a condition in which, a spike or serrated edge of nail has pierced the epidermis (superficial layer of skin) of the sulcus and penetrated the dermal tissues. It occurs most frequently in the big toe of male adolescents and may be unilateral (affecting one side) or bilateral (affecting both sides). Initially, it causes little inconvenience, but as the nail grows out along the sulcus the offending portion penetrates further into the tissues and promotes an acute inflammation in the surrounding soft tissues which often becomes infected.

Causes of Ingrown Toenails

The most common predisposing factors are faulty nail cutting, hyperhidrosis (excessive sweating of skin) and pressure from ill-fitting footwear, although any disease state which causes an abnormal nail plate due to fungal nail infections for example, may promote piercing of the sulcus tissue by the nail.

 

If a nail is cut too short, the corners cut obliquely, or if it is subjected to tearing, normal pressure on the underlying tissue is removed and without that resistance the tissue begins to protrude. As the nail grows forward, it becomes embedded in the protruding tissue. Tearing of the nails has a similar effect to cutting obliquely across the corners of the nail plate. Both are likely to result in a spike of nail left deep in the sulcus, especially if the nail is involuted. Any spike left at the edge of the nail increases the risk of sulcus penetration as the nail grows forward.

 

Maceration of the sulcus tissue is commonly due to hyperhidrosis (excessive sweating of skin) in adolescent males but may also arise from the overuse of hot footbaths in the young or elderly. Moist tissue is less resistant to pressure from the nail such as that caused by lateral pressure (side pressure) from narrow footwear or abnormal weight-bearing forces, for example pronation (collapsed arches or the rolling in of the feet), and as compression forces the lateral nail fold to roll over the edge of the nail plate, the sulcus deepens and the nail may penetrate the softened tissues.

 

Treatment of Ingrown Toenails

If the ingrown toenail is uncomplicated by infection, the penetrating splinter may be located by careful probing and then removed with a small scalpel or fine nippers. The edge of the nail can be smoothed with a small nail rasp to reassure that there is no remainder of the serrated edge of nail. The area is then irrigated with sterile solution and dried thoroughly. It should then be packed firmly with sterile cotton wool or gauze, making sure that it is inserted a little way under the nail plate to maintain its elevation. An antiseptic astringent preparation, such as Betadine, is applied to the packing and the toe is covered with a non-adherent sterile dressing and tubular gauze. If there is associated hyperhidrosis, this requires an appropriate regime while the ingrown toenail is being treated.

 

When the ingrown toenail is complicated by infection and suppuration (pus) is present, it is imperative to remove the splinter of nail, facilitating drainage and allowing healing to take place. Hot footbaths of magnesium sulphate solution or hypertonic saline solution may be used to reduce the inflammation and localize the infection before removal of the splinter is attempted.

 

If conservative treatment does not provide long term relief, nail surgery will invariably be necessary. Partial nail avulsion (PNA) is a minor procedure that permanently removes a section of nail plate. Firstly, this involves two injections of local anaesthetic at the base of the affected toe. The offending section of nail is then removed and the nail matrix/root (cells responsible for nail growth) is burnt using a chemical technique. This prevents the section of nail from regrowing. Finally, a thick, absorbent aseptic dressing is applied. As no sutures are required for this procedure, in most cases minimal pain is experienced post-operatively.

Written by David Chen

Senior Foot Care Podiatrist

 

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