Ingrown Toenails

What is Ingrown Toenails?

An ingrown toenail, also known as onychocryptosis or unguius incarnatus, is the most common toe nail issue that doctors in podiatry, general family practice, and dermatology see. An ingrown toenail happens when the toenail grows into the surrounding skin, leading to inflammation and infection. This condition can cause considerable pain and discomfort, and even disability if not treated properly. Ingrown toenails can occur at any age, but they are most common in teenagers and young adults. The big toe is the most common location for an ingrown toenail. There are different ways to manage this condition, ranging from basic treatments to extensive surgery, depending on how severe the condition is and at what stage it’s caught.

What Causes Ingrown Toenails?

The main cause of ingrown toenails seems to be cutting the nails incorrectly. This can cause a sharp part of the nail to dig into the surrounding soft skin. Other things that can make ingrown toenails more likely include wearing shoes that are too tight, not keeping the feet clean, excessive sweating, injuries, and certain medications, particularly those that interfere with the skin’s growth process.

There’s been a lot of discussion about whether features you’re born with, like the shape of your nail or your toe’s anatomy, can contribute to ingrown toenails. Some research has suggested that having unusually curved nails, wide nail plates, toenails that don’t align properly, or thick nails might increase the risk of getting an ingrown toenail.

Some other studies have suggested that abnormalities in the bones that might increase pressure in the ankle, foot, or toe could contribute to ingrown toenails. However, more recent studies have suggested that there’s no difference in these anatomical features between people with ingrown toenails and those without them.

Risk Factors and Frequency for Ingrown Toenails

Ingrown toenails are a health issue that hasn’t been widely studied. However, it’s known that between 2.5% to 5% of people suffer from them. The number of people with ingrown toenails has been increasing, which could be due to greater health awareness or lifestyle changes like intense physical activities. They are most common in teenagers and adults, affecting males twice as much as females. Ingrown toenails mainly occur on the big toe and can occur on either or both sides of the nail. They are twice as likely to happen on the side of the toe rather than the middle.

• Ingrown toenails affect between 2.5% to 5% of people.
• The numbers are increasing, possibly due to more health knowledge or increased physical activities.
• They commonly occur in teenagers and young adults, with males affected twice as often as females.
• Ingrown toenails mostly affect the big toe.
• They can occur on one or both sides of the nail, but are twice as likely to occur on the side.

Signs and Symptoms of Ingrown Toenails

An ingrown toenail is a condition that’s easy to identify because almost everyone with it experiences pain in their toe. This pain can vary, making it hard for some people to walk or, in severe cases, prevent them from walking altogether. Depending on the stage of the ingrown toenail, symptoms seen on physical examination can differ.

The earliest stage (stage 1) is marked by inflammation in the affected toe, which includes pain, swelling, and redness. This is followed by stage 2, which involves an acute infection with pus drainage and nail fold ulceration, leading to even more swelling and soreness. If the infection turns chronic, it progresses into stage 3 and leads to the growth of overactive tissue. This tissue increases the pressure, contributing to additional swelling and discharge.

• Stage 1: Pain, swelling, and redness in the affected toe
• Stage 2: Acute infection with pus drainage, nail fold ulceration, increased swelling and tenderness
• Stage 3: Chronic infection, growth of overactive tissue leading to more swelling and discharge

Testing for Ingrown Toenails

If you’re experiencing symptoms of an ingrown toenail, your doctor can typically diagnose it by just looking at your toe. You usually don’t need any blood tests or x-rays.

However, if during your physical examination your doctor finds a lump under your toenail (a ‘subungual nodule’), they might order for an x-ray. This is done to make sure you don’t have a condition known as ‘subungual exostosis’, where there’s extra bone growth under the toenail. This condition can be seen on an x-ray as a bony lump.

Treatment Options for Ingrown Toenails

Treatment for ingrown toenails can range from simple home-care solutions to surgical procedures, depending on the severity of the condition and factors like allergies, pregnancy, and bleeding disorders. For mild to moderate cases, usually non-invasive methods are recommended, while severe cases may require surgery.

General care for ingrown toenails begins with wearing proper footwear and correct trimming of the nails–making sure not to overly round the corners of the nails. It is also necessary to manage any underlying causes such as excessive sweating (hyperhidrosis) or nail fungus (onychomycosis). Soaking the affected toe in warm, soapy water or a solution with Epsom salt can provide relief, as can applying a topical antibiotic ointment. Using topical steroids may decrease inflammation caused by excessive tissue growth near the nail.

Non-surgical techniques for managing ingrown toenails include:

• Placing a cotton wisp under the corner of the ingrown nail to lift it away from the skin.
• The “dental floss” technique where a string of dental floss is placed under the ingrown nail to separate it from the skin.
• The “gutter splint” or “sleeve” approach involves a small tube attached along the side of the nail to give immediate pain relief.
• The “taping” procedure, where tape is used to pull the skin away from the ingrown nail reducing pressure and pain.
• “Nail wiring” includes making holes in the nail and inserting a flexible wire to correct the nail’s shape. Other methods involve using nail braces or acrylic nails.

If these methods are not effective and the condition is severe, surgical intervention may be needed, which is typically done under local anesthesia. Various surgical techniques include:

• Removing the affected portion of the nail and part of the nail bed (partial matricectomy).
• Chemical partial matricectomy, where chemicals like phenol are used to remove part of the nail bed, resulting in less pain and more success than mechanical removal.
• Excision of the affected nail and entire nail bed (total matricectomy), which is a more extensive procedure indicated for advanced stages of ingrown toenails.
• A wide excision of the soft tissue around the nail, based on the theory that the issue lies not with the nail but with the surrounding skin.

Newer surgical methods involve technologies like electrocautery, radio frequency ablation, and carbon dioxide laser ablation. While the ideal surgical technique would lead to the best functional and aesthetic outcome and low recurrence rate, it’s worth noting that simple nail removal often results in a high recurrence rate, while chemical methods like phenol matricectomy tend to be more successful.

What else can Ingrown Toenails be?

If a doctor is trying to identify a condition affecting your nails, they might consider several different possibilities. These could include:

• Subungual exostosis, a bony growth under the nail
• Different types of tumors in the nail bed, both benign (non-cancerous) and malignant (cancerous)

They can use an X-ray to confirm the presence of a subungual exostosis. The doctor will also consider malignant, or cancerous tumors like subungual melanoma and the locally aggressive subungual squamous cell carcinoma.

What to expect with Ingrown Toenails

Recurrences, or repeat incidents, can happen after all the procedures mentioned above. They occur when part of the matrix, or the base area where a nail grows from, is not completely removed, and a sharp, tiny, needle-like portion regrows from the side. The risk is highest with simple nail removal, with a 70% recurrence rate.

Certain procedures, like chemical and laser treatments to remove the nail matrix, have lower rates of repeat incidents than mechanical methods of removing the nail matrix.

Possible Complications When Diagnosed with Ingrown Toenails

It’s important to take into account and treat secondary infections of the nail fold and paronychia, along with any scarring of the nail fold.

Notable Concerns:

• Secondary infections of the nail fold
• Paronychia
• Scarring of the nail fold