INGROWN TOENAILS AND WHY THEY CAN BE A BLESSING IN DISGUISE
At Compleet Feet we treat many an ingrown or ‘ingrowing’ toenails. It is not until you have such a problem that you appreciate how painful they are. As a podiatrist I did not fully comprehend how acutely tender they are until I got one myself. The pain of self-treating it literally brought tears to my eyes! Mine occurred just before a Christmas, rushing around then stubbing my big toe, then not really checking it out until it was too late. A New Year party called for me to put on my party shoes and wow the pain! In stubbing my toenail I had split the corner, and a spike was ingrowing into the skin, the groove at the side of the nail called the sulci. It was exquisitely painful and hard to remedy myself despite all my podiatric experience. A large glass of port was required to dull the discomfort, but I am not sure it steadied my hand! I did get the offending nail out, and luckily it rectified itself with me never again underestimating how painful they are to my patients.
I was one of the lucky ones as I could reach my feet and get the spike out, but so many individuals are not able to, or just can’t get the ingrowing section of nail out. Nails can ingrow for many reasons, and generally the majority we see in clinic are the big toenails, but then the big toe, the hallux has a lot of work to do and it is highly innervated. It is you main spring, lever for forward propulsion. Here are some of the reasons for ingrowing nails:
- The nail is involuted in shape and does not grow straight at the free edge so it just grows and turns inwards
- Damage to a nail can result in a spike
- A fungal nail can become thickened and distorted
- A stiff big toe can keep banging onto a shoe’s toe-box resulting in nail trauma
- General poor biomechanics whereby the arch of the foot is collapsing inwards causing the big toe to constantly impact when walking in the shoe toe-box
- Badly fitting shoes, tight socks, surgical stockings
- Sweaty feet
- Poor nail cutting
- Foreign body e.g. hair, splinter
- Fleshy toes whereby the skin tends to encroach on the nail plate
- Nail disease e.g. psoriasis
The above etiological list is quite extensive for why we can get an ingrowing nail, but the results are the same, predominantly pain, swelling and inflammation. A lot of individuals who are experiencing tenderness from their nail often don’t have what I classify as ‘true’ ingrowing nails, they are just nails that are causing pressure. A ‘true’ ingrowing nail actually grows into the skin. If the section of nail piercing the skin is not removed it will continue to grow inwards and become infected, with white or yellow pus forming. The body also responds to the offending nail as if it was a foreign body, and a process of hypergranulation begins to occur. This is when there is an overgrowth of skin around and over the nail. This can be very red and vascular, so readily bleeds. It all becomes very distressing to the sufferer, and they are limited to what shoes they can wear. This can be hugely problematic as it can interfere with work and daily activities.
When an ingrown toenail has reached this point you must go to a qualified podiatrist before a GP. A GP will be able to prescribe antibiotics for the infection, but generally will not be able to treat the nail. I have come across so many cases when individuals were prescribed antibiotics as if that was all they needed to sort the out problem ….WRONG! Nails don’t stop growing inwards. The sooner the troublesome piece of nail is removed the quicker it will resolve.
In my clinic I first gently remove any spike or ingrowing nail section, then pack the sulci, nail fold with cotton wool or a special bacterial wick called Sorbact, which helps to draw away the bacterial infection. Generally this works well for new ingrowing nails, but for the more chronic long standing ones these have to be operated on. Once the process of hypergranulation has started it is very hard to settle until you remove the whole side of the nail plate.
Nail surgery has come on a long way from the days when one would have to have a hospital admission and a general anaesthetic. A procedure called a Zadick’s used to be done. This involved cutting into the base of the growing nail to surgically remove it. Sutures would be required. This is totally unnecessary, ‘belts and braces’ comes to mind. A simple nail surgery procedure can be done within an hour in a clinical setting. This procedure is termed wedge excision or total or partial nail avulsion.
A local anaesthetic needs to be administered to deliver what we term a ‘ring nerve block’. This is done at the base of a toe only, to numb it successfully. The analgesia generally works very quickly. Now for those of a squeamish nature stop reading now…………….I apply a tourniquet to create a bloodless area, prise and elevate the section of nail plate to be removed from the nail bed, do a straight cut up towards to where the nail grows from, clamp the nail with a pair of forceps, roll the nail section inwards and remove. Easy!
To stop the nail growing back, if it is considered to be an ongoing problem, a chemical called phenol is applied for a few minutes to safely destroy the relevant nail cells. It is not always required. If it has been applied, the resulting cosmetic appearance is just that of a slightly narrower nail plate. We never remove more nail than we have to. The healing skin to the side of the plate just shrinks inwards as it heals, and you often cannot see that any procedure has occurred. An operated toe needs a few weeks to heal up completely, and needs to be dressed slightly longer if phenol has been applied. Total healing time 2-4 weeks if you follow all our post treatment advice e.g. avoid stubbing, keep clean.
The relief a patient experiences after nail surgery is immense, and so many people who have had ongoing issues wonder why they did not have the simple nail surgery procedure before. The surgery is never as painful as they imagine, and the great results speak for themselves.
Why it can be a blessing to get an ingrowing nail
Patients after surgery still have to address the reasons as to why they may have got the problem in the first place, e.g. poor fitting shoes, bad toenail cutting etc. Part of my role is to identify and educate people on all of these potential issues. One of the biggest problems I have noticed over the years, as to why people get distorted ingrowing nails is poor biomechanics, which can often manifests in early life as a teenager. I witness a high incidence of teenagers with ingrowing nails, which is often presumed to be due to bad nail cutting, hormones, sport etc, but when I assess them it is because their feet are rolling inwards, pronating. A lowering of the arch tends to jam up, lock the big toe, and it can start to rotate. Often the issue of a controlling orthotic insole can remedy this issue, and go on to be a preventative measure for potential muscular skeletal issues brewing up for later. An ingrowing nail is just the first indication that an individual’s biomechanics need to be addressed, so actually an ingrowing toenail can be a blessing in disguise if you get the right podiatrist who recognises it is as the start of something more.
Please check you medical insurance to see if you can claim for your nail surgey. We are BUPA registered for nail surgery.