Editing Ingrown toenail


''Infection beneath the lateral nail fold or cuticle''

== '''Epidemiology''' ==

* Estimated 2.5-5% prevalence

== '''Risk factors''' (for distal-lateral ingrowing) ==

* Improper nail plate trimming to round the edges
* Poorly-fitting shoes
* Hyperhidrosis
* Repeated minor trauma
* Congenital or acquired foot deformities
* Drug-induced paronychia

== '''Pathophysiology''' ==

* Distal-lateral ingrowing
** A sharp spicule of the distal-lateral nail plate edge penetrates and injures the soft tissues of the lateral nail fold, causing a foreign body, granulomatous reaction
* Distal ingrowing
** Following nail plate avulsion, the hyponychium becomes hypertrophic and the nail plate embeds into the distal pulp
* Retronychia
** Incomplete nail shedding, leading to embedding of the nail into the proximal nail fold and subsequent inflammation

== '''Presentation''' ==

* Stage 1 - Initial embedding of the nail spicule into the nail fold. Slight erythema and swelling. Pain when touching the area or wearing tight shoes.
* Stage 2 - Severe inflammation with seropurulent discharge. Pain can be severe.
* Stage 3 - Formation of granulation tissue, that will undergo epithelialization with hypertrophy of the lateral nail fold.


== '''Differential diagnosis''' ==

* Acute paronychia
* Herpetic whitlow
* SCC

== '''Initial management''' ==

* Cut nail straight, without rounding the corners
* Wear open toe or box toe shoes

== '''Non-operative''' ==

* Cotton nail cast
** Remove the nail spicule
** Lift and separate the nail edge from soft tissue
** Place a piece of gauze or dental floss underneath, to stop the nail growing into the nail fold
** Will need to be replaced weekly until outgrowth
* Gutter treatment
** Cut a piece of IV tubing open to form a gutter, then slide it under the nail to prevent ingrowth (6-8 weeks)

== '''Indications for surgery''' ==

* Severe
* Extremely painful
* Recurrence

== '''Surgical goals:''' ==

* Permanent reduction in width of the nail plate, or a reduction of the periungual soft tissues

== '''Wedge resection:''' ==

* Aim to excise about a quarter of the nail, the nail fold, the nail wall and nailbed
* Ring block
* Glove tourniquet
* Mobilise and excise about a quarter of the nail on the affected side (3-5mm), using Gillies and Metz scissors. Avoid lifting the nail too much in the middle, as that needs to stay intact and attached.
* Lift the nail fold by making an oblique cut at the base of the nail. Options to destroy germinal matrix:
** Excise with scalpel
*** The stuff you need to get rid of is the whitish tissue - basically cut down to bone
** Apply 88% phenol (be very careful not to get any on skin) - Cochrane review demonstrated much lower recurrence rate. Apply paraffin to skin to protect it. Clean skin and apply alcohol to skin afterwards. 
** Diathermy
** Curette
* Close the cut with a single Prolene suture
* Jelonet on top of nail, gauze, crepe
* Review in clinic 2/52 
** Dressing off
** Clean
** Suture out
* Patient can then commence betadine soaks daily and go back to wearing loose shoes

== Zadek's procedure ==

* Indications:
** Recurrent disease after adequately-performed wedge resection
** Patient preference - prior to long periods of inaccessible medical care
* Technique
** As per wedge resection, except remove entire nail
** Ablate entire matrix with phenol

[[Category:Skin, soft tissue and wounds]]