Ingrown nails. They are painful, they can be swollen. They may be red. They may drain…a number of colors of things. So not every ingrown toenail that walks into our office can be treated in exactly the same way. This blog will serve to educate you on ingrown nails and what possible treatments may be needed and recommended.
If you have pain, swelling, redness or drainage from your toenail border, you probably have an ingrown nail. The term ingrown nail truly only describes the shape of the nail. An incurvated or ingrown nail curves at the corner (varying degrees) causing pressure on the skin. In some cases, the natural curvature of your toenail may just not get along with that pointy or tight shoe you wore for a holiday party. In other cases, that corner might bother you regardless of what shoes you wear — or even if you aren’t wearing shoes at all.
So why does the toenail curve in? For some the answer is in genetics. The shape of the toenail can be caused by our genes dictating the amount of curvature to the nails. Some patients of ours come in and relate that their parents or children have the same trouble with their nails. In other cases, the nail shape can change over time to become irritated. The nails can thicken and bend from chronic incorrect shoe gear. Also, injury to the nails can change the way that the nails grow. The change after an injury to the toenail may have been years ago, causing thickening or even a loss of the toenail temporarily. An injury could also include when a nail is overtrimmed during the course of a pedicure. This is a particularly frustrating situation as you may have been just trying to 'treat' yourself and here you end up with an angry toenail that is anything but cute.
So now that we know where they come from, how else are they different? Some ingrown nails are simply placing pressure on the adjacent toe and skin and require simple trimming and use of softening agents to reduce the ‘rock and a hard place’ phenomena as I call it. The nail pushes on the skin, the skin thickens and calluses in response and now you have two hard things putting pressure on those nerves in the skin next to the nail. If a nail is simply painful, but not infected, sometimes a simple trimming can be performed. Some may refer to this as a ‘slant back.’ This means the nail is trimmed and smoothed to temporarily take pressure off and in efforts to get the nail to grow in without pushing into the edge of the nailbed’s skin again. This type of trimming will not resolve an ingrown nail for good, unless of course the nail was irritated only by a certain shoe and does not have a grossly curved edge.
If a nail corner is badly curved in the corner and has chronically caused pressure, irritation or even occasional infections, a permanent procedure (called a P&A/phenol and alcohol or chemical matrixectomy) can be performed to alleviate the ingrown nail for good. A section of nail is removed leaving a straight clean edge and a chemical is applied to kill the growth cells of the nail in a localized area. This means that the nail matrix should no longer make nail and the straight edge of the nail means no more pain. This procedure involves injecting the toe with a numbing agent for your comfort. Once the toe is numb, the nail is removed and 3 applications of phenol are applied, each for 30 seconds. Isopropyl alcohol is used to irrigate or rinse out the border and a larger bandage with gauze is applied. Due to the chemical burn caused by the phenol, these procedures require bandage changing and sometimes soaking for a few weeks until it has fully healed. Permanent procedures, especially the permanent matrixectomy, cause pain for a week or so that diminishes as the border heals.
Another way to permanently remove the nail border is through a sharp resection. This means that the toe is again numbed up, but then the nail matrix is physically cut out and the toe is sutured up (stitches put in). After the skin has healed, stitches come out and the nail should not grow back.
If a patient comes into the office and has redness, swelling, pain and is draining infectious substance (puss), this requires a procedure called an I&D. This stands for incision and drainage. This is NOT permanent. The intention is to allow the infection to drain from the border and a wedge of nail is removed in order to take pressure off the adjacent skin so that the open sore that served as an avenue for the bacteria to get in can close.
If you have a swollen, red, painful ingrown toenail border, but there is no infection present, another non-permanent procedure may be recommended. The nail border can be so painful at times that having your doctor trim it out may not be possible without anesthetic. So, after numbing the toe, your doctor will remove the offending border, rinse the area and ensure no infection is present and then allow the border to heal. These procedures are called partial nail avulsions or PNA’s. These often alleviate the pain of an ingrown nail very quickly.
Research demonstrates that the phenol and alcohol chemical matrixectomy is successful in 98% of cases. In the other 2%, the border may grow back similarly to as prior to the procedure, either over weeks or many years. Another possibility is that only a small portion of the nail regrows (we call this a spicule). If this happens, it may mean that the chemical applied did not adequately damage the growth cells. These spicules sometimes even grow up off of the toe rather than out toward the tip of the toe.
Whether you have suffered from an ingrown toenail in the past that is recurring or you all of a sudden have a painful nail border, a visit to our office can help to alleviate your nail concerns. Our doctors and staff are highly trained to make your visit as comfortable as possible. Call today!