By Gary M. White, MD
An ingrown nail is very common and represents a foreign body reaction of the periungual skin to the edge of the nail. The more the skin inflames, the more the area swells, leading to more pressure by the nail. Secondary infection is common.
The nail gets driven into the tissue which then swells causing a viscous cycle. Young people and the big toe are most commonly affected. Trauma, improper nail cutting and anatomic abnormalities of the nail may predispose.
Various approaches may be used including eliminating shoes that cause direct pressure, reducing exercise that contributes to trauma, warm soaks and oral antibiotics. Some have recommended using tape to pull the tissue back, away from the nail. The patient should be educated on correct nail clipping.
The application BID of a potent topical steroid for a week may help. The steroid should be applied immediately after water-soaking to increase penetration.
Use of a gutter splint is helpful. A plastic gutter is pushed between the nail edge and the ulcer bed. It may be held in place with cyanoacrylate glue [JAMA Derm 2014;150;1359].
If these conservative measures fail, the lateral 1/3 of the nail on that side may be avulsed. If permanent cure is desired and the patient accepts the consequence of permanent nail dystrophy, the nail matrix may be ablated as well.
The patient may be started on an oral antibiotic prior to the procedure. Clean the area and then apply a tourniquet about the affected toe (e.g. glove with tip cut off). After anesthetizing the area either with digital block or local slow infiltration, avulse either a portion or all of the nail. Then, if permanent ablation of the nail is desired, apply 3 times for 30 seconds each phenolic acid (e.g. on a cotton-tipped swab). Avoid contact with normal skin. After controlling bleeding, wrap the toe. Have the patient continue the antibiotic, and clean the area daily with soap and water followed by an antibiotic ointment or grease till healed.
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