Ingrown Toenails
What are ingrown nails?
Ingrown toenails are the most commonly treated nail conditions seen in our clinics. The term "ingrown toenail" is often used to describe a number of problems that lead to pain and discomfort around the nails despite the fact that in many cases, the nail does not actually "grow" in to the skin around it. These problems most commonly occur on the big toe, however, smaller toes can also be affected.
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What causes pain around the nails?
- Improper cutting. A True ingrown toenail (onychocryptosis) is where a small nail spike pierces the skin leading to pain and infection. This normally occurs at the tip of the nail along the sides when a spike in the nail is left from improper nail cutting techniques or trauma. Nails should be cut along the contour of the toe or straight across with rough edges filed so that no spikes are left on the edges where possible. Nails should only ever be cut down the side by a professional. - Poor fitting footwear. Tight shoes restrict room for nail growth and can cause micro trauma which can lead to ingrown nails. - Involuted nails/Incurvated nails. Sometimes nail edges curve into the skin either due to trauma, changes in the bone under the nail or a congenital disorder. - "Chubby toes". People with chubby toes will find the skin at the sides of the toe, is more likely to be traumatized or pierced by the nail as it grows. - Flat Feet can lead to feet turning outwards when walking causing the weight of the body to "roll over the side of the big toe instead of propelling straight over the top. This can lead to compression of the toes and can lead to an ingrown toe nail. The forces that lead to these ingrown nails are often seen in conjunction with callus on the side of the big toe. - Corns, callus, and dry skin down the sides of the nail (onychophosis) can lead to extra pressure and cause pain and even infection. - Genetic. Sometimes the shape of the nails that we have inherited from our parents can put us at a higher risk of developing ingrown toenails such as wider nail plates, "chubby toes", or nails that curl around. - Trauma. Either an acute injury near the nail or anything that causes the nail to be damaged repetitively (such as playing soccer) can also cause an ingrown nail. Common traumas include: once off occurrences such as dropping a brick on your toe; or continual micro trauma such as lots of little knocks from activities such as running, sports or wearing pointy toed shoes |
 Ingrown toe nail  Onychophosis  Involuted Toe Nail |
How is it treated
Ingrown toenails can be treated two ways. Conservatively with care from a podiatrist, a change of cutting techniques, salt water soaks, shower etc. When bad enough, a simple nail surgery can provide quick, lasting relief. Nail surgery can either be permanent or temporary depending on the situation or your preference and can be discussed with your Podiatrist. Whilst surgery is not always required, when it is we simply remove the side of the nail that digs in to remove the pressure from the area to allow it to heal.
Conservative treatment may include:
- Seeing a podiatrist to get the spike, nail edge or dry skin removed. It is often less painful and more effective when done by the right podiatrist. After all, they see plenty of these and are equipped with the right tools for the job.
- Salt water soaks. Whilst they won't cure ingrown nails, they are often recommended as the first step for newly infected nails before antibiotics can be obtained. It is suggested to soak your foot in a salt water foot bath ( 1 tbs spoon of salt in a liter of luke warm post boiled water) for 10 mins and follow by dressing with antiseptic and a bandage until you can get some professional help. See salt water soaks for ingrown nails.
- Taking the pressure off the area. This can achieved by wearing less pointy shoes or using paddings to deflect pressure away from the area of pain such as toe spacers.
- Antibiotics. Antibiotics are important if your nail is infected. However, antibiotics rarely solve the problem alone. Whist the toe may often seem to improve while on the antibiotics, the infection often returns once the course is finished, especially if there is a nail spike piercing the flesh.
- Lifting up the corner of the nail that is digging into the skin. This is done by taking a small piece of cotton or gauze and rolling it to form a small roll or wick. It is then placed between the nail and the skin to keep it elevated to relieve pain and pressure.
- Eliminate the cause of the problem. ie. If it is caused by shoe wear for example, either reduce the time spent in those shoes or look at ways to take the pressure off the area with in shoe padding. If it's genetics and the shape of the nail, then nail surgery may be needed.
Complications:
Cellulitis - Whilst reactive cellulitis (redness in the immediate surrounding area) is quite common, in some cases, such as in a diabetic person, someone with poor circulation or other debilitating illnesses, the infection can spread and you may see an ascending cellulitis meaning the redness traveling up the foot or possibly up the leg and must be treated as soon as possible.
Ulceration or gangrene- Complication in the infection site that may begin to breakdown and lead to ulceration or gangrene. In these cases the person must be seen to immediately.
Granulation tissue- Sometimes ingrown toe nails have a bright red growth coming out of the side of the nail. This is known as granulation tissue and is nothing more than an accumulation of tissue such as blood cells, bacteria and scar tissue in response to trauma and infection. In itself it is nothing serious however it can be quite painful and tends to bleed a lot if traumatized leading to continuous cycles of infection and swelling. When the ingrown nail is removed surgically or resected by a podiatrist, it usually resolves on its own with the help of silver nitrate which is painlessly applied at the time of resection. However, if you notice the granulation tissue keeps coming back (with or without an ingrown nail), it should be removed and biopsied in case of other nasty's.
Surgery:
If ingrown toenails are a recurring problem, it is generally recommend that a podiatrist performs an in office procedure whereby the offending piece of nail is removed either on a permanent or temporary basis.
The most widely used procedure involves a simple nail wedge resection and matrix sterylisation with phenol. This is an "in office" procedure done under local anesthesia. After the ingrown nail is removed, the growth plate (matrix) is destroyed using the repeated application of phenol, a chemical designed to stop the nail growing back. After the local is applied, it is often a fairly pain free experience with most people reporting little to no pain after the procedure and being able to go back to work the next day.
Ingrown toenails can be treated two ways. Conservatively with care from a podiatrist, a change of cutting techniques, salt water soaks, shower etc. When bad enough, a simple nail surgery can provide quick, lasting relief. Nail surgery can either be permanent or temporary depending on the situation or your preference and can be discussed with your Podiatrist. Whilst surgery is not always required, when it is we simply remove the side of the nail that digs in to remove the pressure from the area to allow it to heal.
Conservative treatment may include:
- Seeing a podiatrist to get the spike, nail edge or dry skin removed. It is often less painful and more effective when done by the right podiatrist. After all, they see plenty of these and are equipped with the right tools for the job.
- Salt water soaks. Whilst they won't cure ingrown nails, they are often recommended as the first step for newly infected nails before antibiotics can be obtained. It is suggested to soak your foot in a salt water foot bath ( 1 tbs spoon of salt in a liter of luke warm post boiled water) for 10 mins and follow by dressing with antiseptic and a bandage until you can get some professional help. See salt water soaks for ingrown nails.
- Taking the pressure off the area. This can achieved by wearing less pointy shoes or using paddings to deflect pressure away from the area of pain such as toe spacers.
- Antibiotics. Antibiotics are important if your nail is infected. However, antibiotics rarely solve the problem alone. Whist the toe may often seem to improve while on the antibiotics, the infection often returns once the course is finished, especially if there is a nail spike piercing the flesh.
- Lifting up the corner of the nail that is digging into the skin. This is done by taking a small piece of cotton or gauze and rolling it to form a small roll or wick. It is then placed between the nail and the skin to keep it elevated to relieve pain and pressure.
- Eliminate the cause of the problem. ie. If it is caused by shoe wear for example, either reduce the time spent in those shoes or look at ways to take the pressure off the area with in shoe padding. If it's genetics and the shape of the nail, then nail surgery may be needed.
Complications:
Cellulitis - Whilst reactive cellulitis (redness in the immediate surrounding area) is quite common, in some cases, such as in a diabetic person, someone with poor circulation or other debilitating illnesses, the infection can spread and you may see an ascending cellulitis meaning the redness traveling up the foot or possibly up the leg and must be treated as soon as possible.
Ulceration or gangrene- Complication in the infection site that may begin to breakdown and lead to ulceration or gangrene. In these cases the person must be seen to immediately.
Granulation tissue- Sometimes ingrown toe nails have a bright red growth coming out of the side of the nail. This is known as granulation tissue and is nothing more than an accumulation of tissue such as blood cells, bacteria and scar tissue in response to trauma and infection. In itself it is nothing serious however it can be quite painful and tends to bleed a lot if traumatized leading to continuous cycles of infection and swelling. When the ingrown nail is removed surgically or resected by a podiatrist, it usually resolves on its own with the help of silver nitrate which is painlessly applied at the time of resection. However, if you notice the granulation tissue keeps coming back (with or without an ingrown nail), it should be removed and biopsied in case of other nasty's.
Surgery:
If ingrown toenails are a recurring problem, it is generally recommend that a podiatrist performs an in office procedure whereby the offending piece of nail is removed either on a permanent or temporary basis.
The most widely used procedure involves a simple nail wedge resection and matrix sterylisation with phenol. This is an "in office" procedure done under local anesthesia. After the ingrown nail is removed, the growth plate (matrix) is destroyed using the repeated application of phenol, a chemical designed to stop the nail growing back. After the local is applied, it is often a fairly pain free experience with most people reporting little to no pain after the procedure and being able to go back to work the next day.
Surgery Procedure
a) nail edge gently lifted
b) cutting of nail
c) removal of ingrown nail edge
d) application of phenol chemical
to stop nail growing back again
see Ingrown toe nail surgery
Prevention
In the case of ingrown toe nails, prevention is better than cure. Here are a few tips at preventing ingrown toenails.
- Wearing the right shoes. Shoes that don't rub on the side of your toe or squish them too close together are important to prevent pinching of the skin at the side of the nail. This doesn't mean you have to wear unattractive shoes, it just means that you should choose shoes that won't put any unnecessary forces on your toes.
- Buffing down the thickness on thickened (gryphotic) toe nails. This will reduce pressure on the surrounding skin as well as prevent all sorts of nail nasty's that can occur in thickened nails.
- Proper nail cutting techniques- cutting straight across and not digging down the sides. Make sure edges are gently rounded off so that no spikes exist down the sides.
- Wearing toe protectors with shoes that probably shouldn't be worn from your "Sometimes Shoes" collection. There are many different toe protectors and spreaders that can be used to offload the nail edge so that there is no pressure on the area to cause problems.
Related Stories:
Nail Surgery at Podantics
Salt water soaks for ingrown nails
Nail Problems
Skin and Nail Care
Fungal Nails
Pregnancy and feet
In the case of ingrown toe nails, prevention is better than cure. Here are a few tips at preventing ingrown toenails.
- Wearing the right shoes. Shoes that don't rub on the side of your toe or squish them too close together are important to prevent pinching of the skin at the side of the nail. This doesn't mean you have to wear unattractive shoes, it just means that you should choose shoes that won't put any unnecessary forces on your toes.
- Buffing down the thickness on thickened (gryphotic) toe nails. This will reduce pressure on the surrounding skin as well as prevent all sorts of nail nasty's that can occur in thickened nails.
- Proper nail cutting techniques- cutting straight across and not digging down the sides. Make sure edges are gently rounded off so that no spikes exist down the sides.
- Wearing toe protectors with shoes that probably shouldn't be worn from your "Sometimes Shoes" collection. There are many different toe protectors and spreaders that can be used to offload the nail edge so that there is no pressure on the area to cause problems.
Related Stories:
Nail Surgery at Podantics
Salt water soaks for ingrown nails
Nail Problems
Skin and Nail Care
Fungal Nails
Pregnancy and feet
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