Ingrown Toenail

Ingrown Nails

Who hasn’t suffered with the agonizing pain of an Ingrown Nail at some point in time? The sight of a toe with an Ingrown Nail can be downright frightening to look at. With that red, swollen, throbbing, oozing mess at the end of your foot, wearing a shoe is simply out of the question. When your toe is in this condition it seems like it had a target painted on it. Suddenly the dog steps on your foot every time he’s near, or your children curiously find it necessary to use your foot as a platform to boost themselves. Everything seems to find your toe and bang against it, sending you into orbit.

As common as Ingrown Nails are, a person might think we’d have a good understanding of how to deal with them. The truth is, there is quite a bit of confusion about what causes Ingrown Nails and what could or should be done to treat them. I hope to clear up some of that confusion. The discussion of a topic like Ingrown nails can be lengthy. I’ll do my best to use layman’s terms. I will include the medical term in parentheses for readers who might be interested to know those terms.

The Condition

An Ingrown Nail (Onychocryptosis) is a painful condition where the skin along side the nail becomes swollen and red and may have a fluid discharge (pus). Often times the tissue around the Ingrown Nail bleeds easily and may have what appears to be a “growth” (granuloma) extending over the nail itself. It is not unusual for an Ingrown Nail to become infected (paronychia).

The term “Ingrown Nail” would seem to imply that there is something strange going on with the nail resulting in the nail curving off and plunging into the soft tissue next to the nail. I think this concept of what an Ingrown Nail is can lead to some confusion. There may be occasions when the abnormal growth of a nail causes a problem but, in many cases this is actually not an accurate description of what is happening. I think an Ingrown Nail would be better described and understood if was thought as a conflict between the nail and the skin along side the nail. We will discuss some of the reasons why that conflict occurs later but, thinking about Ingrown Nails as a skin/nail conflict takes the focus off the growth of the nail and takes us down a road where we can appreciate some of the more common reasons we can have this problem.

The Causes

The topic of the causes of Ingrown nail can be controversial. Probably the most common misconception about what causes Ingrown Nails has to do with cutting nails. Often times people who suffer Ingrown Nails are blamed themselves for the problem. It’s not unusual to have a parent, sibling or some other person wag their finger sternly and preach, “ It’s your own fault, you’re not cutting your nails straight across.” The advice of cutting nails straight across may help some of the time but only works in a minority of cases. Cutting the nails straight across not only looks odd, it leaves a segment of pointed nail projecting over the skin which can become the source of the problem. Properly cutting nails is not a “one size fits all” kind of proposition. Some people can cut the nails straight across and do fine. Others do better with the corners trimmed or filed. In general following the natural contour of the toe leaving about 1 millimeter of “white” at the nails end works best but some people may have to experiment to see what works best for them. What is important in cutting nails is that you actually cut them rather than biting, tearing or picking at the nails.These methods of shortening the nails will almost certainly result in an Ingrown Nail eventually.

So to clarify the point, Ingrown Nails are NOT usually caused by not cutting nails straight across but can be caused by tearing, biting or picking at the nails rather than cutting them.

Now that we’ve discussed the common misconception about “cutting wrong” being the cause of Ingrown Nails, we can move on to discuss some of the lesser known but more common causes of Ingrown Nails. I think the discussion will prove at least enlightening if not entertaining.

These lesser known causes of Ingrown Nails can be broken into a two main categories, Trauma induced skin/nail conflict and Growth Pattern induced skin/nail conflict.

Acute Trauma

Imagine you’re playing soccer and you “toe kick” the ball, driving the skin adjacent to the toenail against the edge of the nail, impaling the skin. The tissue surrounding the cut in the skin will likely swell pushing the soft tissue against the nail, creating a self sustaining loop; more swelling leading to more pressure causing more swelling causing more pressure etc. So from kicking a soccer ball to dropping a brick on your toe, to catching your toe on the bedpost, direct trauma is one possible cause of an Ingrown Nail.

Chronic Trauma

Improper fitting shoes can be the underlying cause of an Ingrown Nail. If shoes are either too narrow or too short, the pressure of the shoe against the toe will drive the skin against the nails edge leading to an Ingrown Nail. The pressure of the skin against the nail edge may result in a small cut in the skin causing swelling in the soft tissue which results in greater pressure, causing more swelling and so on. So, ill fitting shoes can be a cause trauma to the toes resulting in an Ingrown Nail.

In some cases a person may have a great toe that is pressing against the neighboring toe, applying continuous pressure against the skin which in turns presses against the nail edge. This type of trauma usually goes unrecognized but produces low level repetitive injury. The cascade previously described begins and results in an Ingrown Nail.

Faulty foot mechanics are another potential source of an Ingrown Nail. Some people walk such that they roll over the inside margins of their great toe. This constant pressure of the ground forces driving the soft tissue into the nails edge can also result in an Ingrown Nail. These people usually have a callus on the inside border of the toe and sometimes on the nail fold next to nail itself.

Growth Problems

Curved Nails-There are several patterns of aberrant growth of the skin and or nail that may result in a Ingrown Nail. Probably most common is the pattern seen is where the nail is curved or arches from side to side. In extreme cases the curvature of the nail results in the nail being oriented sometimes perpendicular to the skin or worse. This relationship of the nail to the skin can lead to the nail edge being embedded in the skin and plowing its way through the skin creating a clear conflict between the nail and the skin.

Wide Nails-Another pattern of growth that can lead to an Ingrown Nail is one where the nail is wide relative to the width of the toe. The excessive width of the nail results in the skin on the borders of the nail being especially vulnerable to pressure from shoes, walking, adjacent toes or the high pressures produced in sports when pushing off with the toes.

Recessed Nails-Some individuals suffer from a nail plate that is positioned “recessed” in the surrounding soft tissues making escape of the nail nearly impossible. These are perhaps the most challenging of Ingrown Nails with complete ablation of the entire nail an a consideration.

Interlocked Nails- Nails and skin are closely related structures that develop alongside one another. In an ideal scenario, the nail and the skin exist side by side, separate from one another. In some cases, the two structures are interlocked with a blurred border existing between them. When an individual who has this problem tries to cut the nail, the clipped nail will not come loose from the skin causing the person to have to pull or cut at the attached nail injuring the adjacent skin, often resulting in bleeding. These individuals will suffer chronic problems at the interface between the skin and nail resulting often times in chronic recurring swelling and pain and Ingrown Nails.

One common denominator that is found running through most of these lesser known causes is “pressure”. I think it can safely be said that anything that results in the nail and the adjacent skin to press against one another could cause an Ingrown Nail to develop.

Treatments

The treatment for an Ingrown Nail is divided into short term treatment and long term treatment. Multiple factors must be considered to appropriately treat the condition. The most important factors are 1)Infected versus uninfected, 2)The source of pressure, 3) The history of the problem, 4)The age of the person, 5)The Circulation and finally, 6) The timing of procedures.

Infection vs uninfected

First, we consider whether or not the toe appears to be infected. The signs of infection include redness, swelling, pain and sometimes purulent (milky white, green or brown) drainage and there may be an odor. If the toe is infected a course of antibiotics will likely be prescribed. It is important to understand that just taking antibiotics alone will usually not clear up an Ingrown Nail. The offending nail border needs to be cut back. Without removing the source of the pressure on the skin, the Ingrown Nail will usually not resolve. Typically when antibiotic alone is used, temporary improvement in the Ingrown is experienced followed by a quick relapse.

Source of Pressure

The ideal treatment for any medical condition should be based on an understanding of the root cause of the problem. If we expect reasonably good results in treating Ingrown Nails we must carefully consider what is causing the Ingrown Nail. If the person complaining of an Ingrown Nail has a bunion where the great toe is pressing against the neighboring toe and the Ingrown Nail is on the side where the two toes contact one another addressing the toe conflict may be necessary. A toe spacer would be expected to help. Cutting the nail border back also would help. A permanent narrowing procedure would likely help. If the problem appears to be primarily one of aberrant nail shape, width or growth our focus would be on procedures to reduce the pressure being caused by the aberrant shape.

History

When treating an Ingrown Nail we consider if the Ingrown Nail is a first time event or if has been an ongoing problem. In cases where the event is a first time experience we focus in resolving the Ingrown Nail and clearing infection if present. The nail border is shaped in such a way as to encourage it coming in without irritating the adjacent skin. There is no indication for doing a permanent procedure in a person with no previous history of problems.

In cases where a person has repeated episodes of an Ingrown Nails at a particular site, a permanent solution is offered so long as there is adequate circulation and there are no other reason not to do the procedure. The procedure performed is called a “Matrixectomy.” A matrixectomy usually is done as a partial matrixectomy with only the offending portion of the nail being removed. The procedure involves numbing toe toe with an injection and then cutting down the side of the nail where the problem exists, removing a 3-4 mm wide section of the nail. The removal of the nail results in exposure of the nail bed and the main growth center (matrix). The exposed nail bed and growth center are then treated with a chemical that prevents those tissues from producing nail in the future. The final result is a nail that is narrower with the goal being to permanently remove the portion of nail that repeatedly has problems.

Age of the Patient

Patients at either extreme are treated with caution and restraint. Infants and toddlers often outgrow this condition and can require a trip to the operating room to address a recurrent Ingrown Nail. The elderly often have reduced circulation precluding performing permanent procedures. Patients in the age range from 8-45 with recurrent Ingrown Nails are potential candidates for the permanent corrective procedure. If younger patients are very anxious, they can be considered for outpatient minor surgery so they can be “asleep” for the procedure. As patients get older, 45 years old or older, special attention is focused on their circulation to make sure their blood flow is adequate for healing.

Circulation

The circulation needs to be assessed when a person complains of an Ingrown Nail. It is not uncommon for an elderly patient to complain of what they think is an Ingrown Nail only to discover their is pain actually from poor blood flow. Additionally, It is essential that patients have adequate circulation to heal should a permanent procedure be undertaken.

Timing

It is extremely important that a toe that has an infection NOT have a permanent procedure performed. The infection must be cleared up first and then the permanent procedure is done. Performing a permanent procedure while the toe is infected risks causing a bone infection. Bone infections are serious medical problems and can result in the amputation of the toe. If there is any doubt as to whether an Ingrown is infected, it is treated as infected, and the permanent procedure is delayed until after the infection has been cleared.

Summary

In summary, Ingrown Nails are very common but how you cut the nails doesn’t matter as much as not picking, biting or tearing them does. In order to treat the condition a thorough understanding of the cause is necessary or the problem will persist. Many of the lesser known causes of Ingrown Nails are pressure related problems that lead the a skin/nail conflict. Pressure induced Ingrown Nails need to have the cause of the pressure addressed. In cases where a permanent removal of the nail is undertaken, adequate blood flow must be confirmed. Permanent removal of an ingrown nail should never be performed if there is a possibility the Ingrown Nail is infected. The procedures should be staged performing the permanent procedure after the infection has cleared.

I hope the reader finds this information helpful and informative. If you happen to suffer from Ingrown Nails or know someone who does, come in today for an evaluation and discuss your options. We would be delighted to help you make Ingrown Nails a thing of your past.