Do you ever get pain in your toenail and wonder if it's an ingrown nail? And, if it is, why does it hurt so much?  Right now, our feet are still under cover. But soon, warm weather will be upon us, and our toes will come out to shine.  So let's make sure they're at their healthiest: and growing in the right direction! 

How Do I Know If I Have An Ingrown Nail?

Anyone, at any time, can develop an ingrown toenail. More often than not, the hallux nail (big toe) will be the one with the problem.  Ingrown toenails present in degrees of complication: sometimes, they're   just a nuisance, but other times they arrive with an all-out infection.  If you have pain to the inner or outer fold of the toenail, you may have an ingrown nail. If there is a break in the skin at the nail border, swelling, or drainage, you most probably have an ingrown nail. 

The nail has 2 borders, the medial border and the lateral border.  The medial border is the edge of the nail closest to the midline of your body, where the lateral border is the border facing away from the midline, or towards the outside end of your body.  An ingrown nail causing pain and/ or infection in either the medial or lateral borders can occur individually, or both borders at the same time.


What Can Cause This Discomfort And Possible Infection?

Toenails are meant to grow straight and outward towards the end of the toe.  However in some patients, the toenail will grow into the skin and appear incurvated, or curved, into the skin.  As the nail grows, it pushes into the adjoining skin, causing discomfort.  This is why an incurvated nail hurts when you touch it.  If the nail continues to push into and through the skin, this causes a break in the skin.  This is a perfect entry for bacteria.  It has nothing to do with hygiene – the bacteria that is the usual culprit, Staph Aureus, is everywhere and enters through the tiniest break in skin due to the ingrown nail. 


How Do I Know If My Ingrown Nail Is Infected?

If you see redness on the nail border, swelling, or drainage, then the bacteria may have caused an infection.  If the condition is ignored, the redness and swelling will increase and may even cause a puss pocket.  The drainage you see may be purulent, or thick and yellowish, and there may be an odd odor.  You may see this drainage on your sock or in your shoe.  If it is not treated, the condition can progress and you may see a soft tissue growth that looks like a red raspberry, called a granuloma.  This is simply your body’s reaction to the infection and inflammation that is caused by the ingrown nail.  At that point, it is definitely infected and you need to get immediate attention by one of our doctors.

How Did I Get It?

The shape of the nail is genetic.  If someone in your family has incurvated nails and you have the same genes, then your incurvated nails come from there.  However just because you have incurvated nails, this does not necessarily mean you will get an infected ingrown one.  The shape of the nail plus other factors contribute to the condition.  For example, we see infected ingrown nails in kids (and adults!) that “pick” at their nails.  If this is a habit, then you may increase your chance of getting an infection.  If you go to a pedicure salon and they dig into the edges of the nail, this may irritate the nail bed and inflame the nail borders and cause a vicious cycle of an aggravated nail border growing into a swollen and aggravated and inflamed side of the toe, causing further nail incurvation and penetration into the skin.  In addition, it can occur when something is hindering the proper growth of the nail, such as tight socks, tight shoes or pointed shoes that squeeze the toenail sides into the nail.  We have also seen an increase in the incidence of ingrown nails in pregnant women.  Because some women’s feet swell in pregnancy, this causes shoes that once fit well to now fit too tightly, causing pressure on the ends of the toes and thus in turn causing an ingrown nail.

A nail infection can not only occur at the medial and lateral borders of the nail, but it can also occur at the base of the nail.  You will experience puffiness, or swelling, at the base of the nail, redness, and possible purulent (puss) drainage.  The redness may travel past the toe.  In this case, it is still considered an ingrown nail, but just not ingrown at the borders.  It is pushing down, or growing, into the skin under the nail base causing pain and a possible bacterial entry for an infection.

How Do I Treat An Ingrown Nail?

If you find yourself unable to come to the office immediately to see one of the doctors, you can start by soaking the affected foot in warm water and antibacterial soap for a few minutes twice a day.  This emersion in water will draw out any drainage from the ingrown nail if it is infected.   You can also try to use cream to soften the area around the nail.  Our office recommends 20% urea cream, you can purchase this at the office.  After a shower or after soaking, use a little bit of cream and massage the nail skin border away from the nail.  This may alleviate some of the pressure on the incurvated nail. 

The best course of action is to make an appointment with of the doctors at Prairie Path Foot and Ankle Clinic.  If there is no break in the skin and the nail is simply incurvated and growing in to the skin, then the doctor will use her instruments and a special technique to cut away part of the nail border.  Very often this results in immediate relief.  If the doctor determines there is an infection, then she may have to perform a procedure, called an incision and drainage (I&D), to alleviate the pain.  The procedure is done right in the office in our procedure room with local anesthetic (lidocaine). You will be able to walk out of the office pain free.  If the doctor sees that there is a localized bacterial infection, then she may also prescribe oral antibiotics after the procedure in order to make sure all of the bacteria is gone.  Your doctor will also dispense the Amerigel wound care kit.  It is a kit that contains all of the necessary items to treat your post op nail wound. 

How Do I Prevent This Ingrown Nail From Coming Back?

Once the doctor treats you to get rid of the ingrown nail, whether it is using instruments to trim it out or a procedure to remove the nail, there are techniques to preventing recurrence.  The most important is to cut your nails straight across.  If you try to “dig” at the corners, they will only become irritated.  If you pick your nails, stop picking at them!  And if it was caused by tight shoes or socks, then be sure to re evaluate your shoe size and your sock size and choice. 

What If It Does Come Back?

If it does happen to return, then our doctors can perform an elective procedure in the office called a matrixectomy.  This procedure, like the incision and drainage described above, is done under local anesthesia.  The purpose of this procedure is to remove the nail border permamently, so only the edge of the nail that grown into the skin will be removed.  The whole nail is not removed, only the affected border.  The nail appears exactly the same, just a few millimeters smaller in width.  The doctors will remove the border, (the nail piece/border removed is no larger than the size of a toothpick) then apply a chemical into the corner to destroy any nail cells from growing again.  After the procedure, the Amerigel wound kit is dispensed, just like for the incision and drainage procedure.  The post op course for this procedure is a little different than the I&D.  With the matrixectomy, there tends to be slightly more drainage and may have more irritation as the body adjusts to the lack of a nail border and is healing the procedure.  There are follow up visits to check the progress and in order for the doctor to examine the nail border until it is completely healed.

The most important caveat from this information is to understand that any time you have a question about your foot, whether it be something on your skin to any pain in the muscle, tendons, or bones of the foot, make an appointment to see your podiatrist.  Here at Prairie Path Foot and Ankle Clinic, we will do a thorough exam and formulate a treatment plan for you.