As podiatrists we regularly treat ingrown toenails (onychocryptosis), or more aptly should be called ‘ingrowing’, as the nail plate grows forward and embeds itself deeply into the skin and soft tissues. Having an ingrown nail is excruciatingly painful especially when it is the big toe. The big toe is highly innervated with nerves for proprioceptive feedback during gait. In Reflexology the big toe represents the head and brain. One should never under-estimate how painful having an ‘ingrowing’ toenail can be. If not treated early they can become inflamed and infected with an overgrowth of healing tissue called hypergranulation, which can grow over the irritating nail spike to occlude it. This hypergranulation tissue can be very fleshy and vascular making it hard to reach the damaged nail. The body is basically treating the nail as an unwanted foreign body, therefore it needs to be removed to halt this over-healing process.

No course of antibiotics is going to resolve a chronic ingrown nail, but unfortunately patients seek initial help with their painful toes by going to their GP, when they should make an appointment with a podiatrist. The offending nail section needs to be removed and the quicker the better for a less invasive procedure. If an ingrowing nail is removed early there is less of a potential issue with overgrowth  hypergranulation issue and having an injection. The problem can be resolved conservatively.

CASE OF A CHRONIC INGROWN TOENAILS

Patient C attended clinic January 2017 with a protracted history of problematic ingrowing toenails. As a child he had the unfortunate habit of picking his big toenails causing formation of painful spikes and damage to the nail folds. It was suggested at the time to have nail surgery to resolve the problem, but the patient felt he could manage the problem conservatively.

May 2018 patient rebooked into clinic requiring an urgent appointment: “My big toenails are so sore, pussey and bleed a lot”. On examination he presented with chronic ingrown toenails of both big toes. The left was more severe in nature with only a small 1cm portion of the nail plate being evident. The nail looked too small for the toe. He was again advised to have surgery and he made no hesitation this time to get them treated. The decision was made to totally avulse, remove both nail plates and use phenol to chemically cauterise the matrix to stop any regrowth. There was too much tissue overgrowth and damage to the nail folds. There was also the risk the patient would continue to pick and have future ongoing issues. The patient just wanted to be pain free. He must have been in considerable discomfort for quite some time.

BEFORE SURGERY

Chronic ‘ingrowing’ toenail. Note how small nail plate looks. 1/3 of nail plate hidden under hypergranulation scar tissue.

POST SURGERY

Nail plate avulsed from the fleshy folds. Still partially attached. Note how much nail had been occluded.