Ingrown toenail is a combined pathology of the nail plate and the periarticular roller, affecting the big toe, requiring surgical correction. The nail plate is gradually pressed into the soft tissues, as a result of which the nail bed narrows from the sides. The periarticular roller becomes inflamed, ulcerated, covered with granulations. There is significant swelling and soreness of the first finger. The diagnosis is made on the basis of general examination data, X-ray examination. Conservative treatment is aimed at reducing the severity of inflammation, orthopedic and surgical ‒ at creating conditions for proper growth of the nail plate.
L60.0 Ingrown toenail
In the medical literature, an ingrown toenail has the synonymous name onychocryptosis. The incidence of pathology in the population is 1.8%. An ingrown toenail on the big toe, according to various sources, accounts for from 3 to 10% of all reasons for seeking medical help in surgical departments of polyclinics. Onychocryptosis is diagnosed in patients of all ages, including children, but most cases occur in people of working age. In women, an ingrown toenail is detected more often than in men.
Ingrown toenail on the thumb belongs to the number of polyethological diseases. Its development is caused by a combination of internal and external factors. Without their identification and elimination, it is impossible to achieve recovery. The most significant factors include:
- Anatomical features. The development of pathology is facilitated by the U-shaped shape of the nail plate on the thumb, the C-shaped shape with beveled edges, the deviation of the periarticular rollers above the plane of the plate. In these cases, the direction of growth of the lateral edge of the nail coincides with the direction of displacement of the soft tissues of the phalanx during movement.
- Anomalies of the structure of the feet. Flat feet, uneven development of the muscles of the foot lead to a change in the configuration of the joints of the fingers of the lower extremities. The most important is the valgus deformity of the thumb, the “bone on the legs”. Inadequate load redistribution disrupts the growth of the nail.
- Unprofessional pedicure. The development and recurrence of pathology is provoked by improper processing of the free edge of the nail on the thumb, excessively low cutting, rounding of free corners. When performing a pedicure, it is advisable to leave at least 1 mm of the overgrown free edge, and make the cut line straight rather than rounded.
- Damage to the nail matrix. The reason for this may be careless cuticle treatment during pedicure, removal of the toenail with sub-elbow panaritia, other diseases. The result of the damage is a change in the direction and nature of the growth of the plate, which leads to its ingrowth into the tissue.
- Increasing the load on the feet. An ingrown toenail develops when wearing high-heeled shoes, a sharp increase in body weight, a change in lifestyle or profession, when a person spends a lot of time in a standing position, walks or runs a lot, gets other loads.
- Wrong choice of shoes. Tight shoes, unsuitable in size, model shoes with sharp noses press on the nail phalanx of the thumb. The direction of growth of the plate in this case changes as a result of damage to the matrix and physical impact on the free edge.
Genetic predisposition is important in the development of pathology, which is manifested by excessive development of the fatty pad and periarticular rollers of the distal phalanx of the 1st toe, metabolic disorders, some endocrine and somatic diseases. With onychomycosis, the plate on the leg acquires increased softness and elasticity, which contributes to its curvature. Hyperhidrosis of the feet leads to softening of the tissues of the periarticular roller, reducing their natural bacterial resistance. Local hypothermia disrupts metabolic processes, slows down regeneration.
Under the influence of provoking factors, pathological changes occur in the germinal zone. The plate begins to grow laterally, deformed. Damage to the skin and subcutaneous tissue is accompanied by the development of acute and then chronic inflammatory process. During the period of increasing symptoms, the formation of panaritium or phlegmon is possible. The proliferation of connective tissue with prolonged existence of pathology leads to the formation of hyperplastic scars, foci of keratosis, keratomas.
The pathological process on the thumb can be one- and two-sided. In their work, specialists use the classification of onychocryptosis, which takes into account the features of the clinical picture of the disease. According to this classification, an ingrown toenail undergoes three stages of development:
- Easy. Changes in the plate during the inspection are not detected. There is moderate swelling and inflammatory infiltration of the periarticular rollers on the thumb. There is no suppuration.
- Moderate. The tissues of the terminal phalanx are hyperemic, edematous, infiltrated. The nail is covered with creeping granulations, its plate is compacted, dull.
- Heavy. The plate is thinned and brittle. The periarticular rollers are edematous, covered with hypergranulations. When both nail rollers are affected, the volume of the phalanx on the leg increases by 1.5 times.
Symptoms of ingrown toenail
The disease has a number of characteristic external manifestations: this is a deformation of the nail plate due to the influx of soft tissues on it from the periarticular roller and manifestations of the purulent-inflammatory process of varying severity. Externally, the affected phalanx on the leg looks as if the nail is immersed in the tissue. The roller on one or both sides begins to grow from the periphery to the center, becomes inflamed, injured, ulcerated and covered with granulations. Granulation tissue forms growths that further constrict the bed.
With inflammation, the roller and the surrounding tissues swell, become red and hot to the touch, pain joins. It is difficult for a person to put on shoes, walk, as any pressure increases pain. Purulent melting of tissues leads to the appearance of panaritia. Pus in most cases breaks out on its own, but surgical opening of the lesion may also be required. With a severe form of ingrown toenail, suppuration may be permanent or periodic.
People who have anatomical prerequisites for ingrown nails periodically note transient symptoms of the disease. Foci of hyperemia, swelling, and minor soreness appear on the thumb. The appearance of symptoms is often preceded by intense physical exertion on the lower extremities, wearing tight shoes.
In patients suffering from ingrown toenail, the risk of developing osteomyelitis of the bones on the legs increases. The probability of the spread of pyogenic microorganisms in the tissues increases the presence of diabetes mellitus, immunodeficiency, severe concomitant pathology in the patient. A decrease in local protective reactions leads to more frequent detection of mycoses and warts in individuals with onychocryptosis. It is reported that a long-existing ingrown toenail can cause the formation of hemangiomas with recurrent bleeding, fibroids, malignant neoplasms.
It is not difficult to identify an ingrown toenail. A complex of clinical trials is prescribed to the patient in order to exclude complications of the underlying disease. If surgical treatment is planned, the test results allow you to establish possible contraindications. In order to diagnose an ingrown toenail on the thumb, the surgeon must conduct:
- Visual inspection. The characteristic appearance of the thumb, the presence of predisposing anatomical features, signs of inflammation, bleeding or pus discharge allows you to make a diagnosis, determine the severity of the process. Complex treatment is selected taking into account the width of the bed and other external signs.
- X-ray examination. An X-ray of the thumb is performed in two projections to identify signs of the spread of purulent inflammation, the transition of the pathological process to underlying structures: the bones of the phalanges, joints. Radiography is indicated only in severe cases, therefore it is prescribed to a small number of patients.
Ingrown toenail treatment
The main cause of relapses of onychocryptosis is a long–term purulent-inflammatory process in the surrounding tissues. If the inflammation is not stopped at the preparatory stage, no surgical technique can guarantee the patient a satisfactory result. In this regard, an ingrown toenail requires a comprehensive approach to treatment.
The purpose of prescribing conservative therapy is to eliminate symptoms with mild severity of the disease, prepare for orthopedic and surgical treatment ‒ with moderate and severe. The patient can carry out most manipulations and procedures independently at home, thereby controlling the course of the disease. The therapy of the disease includes:
- Local anti-inflammatory treatment. A good therapeutic effect with a pronounced purulent-inflammatory process is given by foot baths with potassium permanganate, sea salt, lotions with rivanol and furacilin, compresses with ethyl alcohol. With mycoses, antifungal drugs and keratolytics are prescribed.
- Ensuring the free growth of the nail. The overhanging roller is pushed away with strips of gauze soaked in wound-healing ointments. To do this, a gauze or bandage is inserted under the ingrown edge of the plate, fixed on the phalanx of the finger. Instead of fabric, special plywood or plastic splints can be used.
It is more preferable than surgical in patients with uncomplicated course of the disease without pronounced purulent-inflammatory processes in the tissues. It is possible to achieve recovery and prevent the development of relapses without surgery, incisions and scars. Of the orthopedic structures in polyclinic practice , they are more often used:
- B/S plates. They are made of durable plastic, fixed with glue. They have a central part and side arches that rest against the side surfaces of the circumflex rollers. The design, provided it is worn for a long time and timely replacement, allows you to remove the corners of the nail from the tissues.
- Milling cutter staples and THIS. The first has the form of a wire structure with hooks at the ends. Hooks lift the edge and prevent ingrowth. When there is no technical possibility to install the Milling cutter bracket, this bracket is used – a bracket made of medical steel, which brings the edges of the nail outwards, contributing to the alignment of the nail plate.
- Goldstadt half-braces. They are made individually according to the impression from the patient’s phalanx. They consist of a hook and a bracket, which is fixed on the surface of the nail plate. They are mainly used to correct unilateral deformations, provide alignment of the free nail edge.
An additional effect can be obtained by sawing the nail plate. At the same time, the growing nail begins to gradually unfold and free itself from the soft tissues covering it. Orthoses, which are made by a podologist on an individual basis, allow to correct the existing deformations of the feet.
The patient is referred for surgery to remove an ingrown nail in cases where conservative treatment and orthopedic techniques do not give results or the result achieved is unstable. Surgical treatment is indicated for patients with the transition of purulent inflammation to the bones of the phalanges, soft tissues of the foot. An ingrown toenail can be operated on in several ways:
- Resection of the nail plate. During the operation, a part of the nail plate is removed, which gradually sinks under the periarticular roller. If you resect the nail without a fragment of the germinal zone, then a relapse will develop after a short time. Simultaneously with the edge zone, the matrix is resected.
- Removal of the nail plate. Traumatic surgery with a long recovery period. Excision of the plate is carried out in such a way as not to touch the tissues along the periphery of the sub-elbow bed, in particular, the germ zone. After surgery, the nail on the thumb gradually grows back, which can cause a recurrence of ingrowth.
- Plastic podnogtevogo bed. After excision of the plate, the treatment of the footbed is performed. By mechanical means, laser, aggressive chemical solutions, the marginal fragments of the germinal zone are destroyed. In the postoperative period, the nail narrows significantly, which prevents it from growing into the rollers on the sides.
Radio wave, laser removal of ingrown toenail. Methods of physical influence are actively used in modern surgery. They allow you to remove the affected tissues, relieve inflammation, and reduce the intensity of pain. Coagulation of blood in the vessels when tissues are heated under the influence of radio waves and a laser makes the operation almost bloodless.
Prognosis and prevention
An ingrown toenail is not a life-threatening condition, but it can significantly limit a person’s daily activity, leading to temporary disability for up to 3 weeks. Surgical and orthopedic treatment is effective in 30-80% of cases. The result of surgical intervention is often disfiguration of the nail bed area on the thumb, which is due to the development of scars at the site of surgical incisions.
It is possible to reduce the likelihood of ingrowth even if there is an anatomical predisposition. To do this, it is necessary to monitor the correct development of the feet from childhood, to select comfortable shoes suitable for size, season, and nature of physical activity. It is necessary to cut off the free edge of the nail at the same level with the soft tissues of the tip of the nail phalanx. Corners can be rounded slightly.