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Onychocryptosis, commonly known as ingrown nails (unguis incarnatus), is a common form of nail disease. It is a painful condition in which the nail grows or cuts into one or both sides of the nail bed. While ingrown nails can occur in both the nails of the hand and feet, they occur most commonly with toenails.
Cause
While many things can cause ingrown nails, the most common causes are improperly fitted shoes and nails that are improperly trimmed. Shoes or stockings that are too tight press on the sides of the nail, causing it to curl and dig into the skin. Nails that are cut too short, rounded off at the tip, or are peeled off at the edges versus being cut straight across are more likely to become ingrown as well. Other causes include an abnormally shaped nail bed, trauma to the nail plate or toe and other nail deformities. Proneness to nail deformities that cause ingrown nails can also be genetic.
Symptoms
Symptoms of an ingrown nail include pain along the margins of the nail, caused by granulation that occurs around the aforementioned region, worsening of pain when wearing shoes or other tight articles, and sensitivity to pressure of any kind, even that of light bedding. By the very nature of the condition, ingrown nails become easily infected unless special care is taken to treat the condition early on and keep the area as clean as possible. Signs of infection include redness and swelling of the area around the nail, drainage of pus and/or a watery discharge tinged with blood. The main symptom is swelling at the base of the nail on whichever side the ingrowing nail is forming.
If Left Untreated
If an ingrown nail is left untreated, it risks infection. When the skin around the nail gets infected, it begins to swell up and put even more pressure against the nail. In the worst case, the swelling will begin putting sideways pressure on the nail causing it to grow at a slant. This will cause both sides of the nail to eventually become ingrown and swollen. Eventually the swollen parts of the skin will begin to harden and fold over the nail. An untreated ingrown toenail will cause a person to walk with a slight limp, which in a long period of time may cause further pain and injury in a foot or leg due to improper distribution of weight. Amputation of the toe may be the final outcome if the infection is left untreated for several months and turns to gangrene.
Prevention
The most common place for ingrown nails is in the big toe due to improper nail trimming. Ingrown nails can be avoided by cutting nails straight across; nails should not be cut along a curve, nor should they be cut too short. Footwear which is too small, either in size or width, or those with too shallow a 'toe box' will encourage any underlying problem with a toenail to get worse. Ingrown toe nails are a disease of the West, and are virtually unknown in cultures that do not wear enclosed shoes.
It is a myth that a V should be cut in the end of the nail to treat an ingrown toe nail. The apparent reasoning behind this is that if you cut a V in the nail, the edge of the nail will grow together as the nail grows out. This does not happen - the shape of the nail is determined by the growing area at the base of the toe, not the end.
Treatment
Treatment of ingrown nails ranges from soaking the afflicted area to surgery. In mild cases, doctors recommend daily soaking of the foot or hand in a mixture of warm water and Epsom salts and applying over-the-counter antibiotics while allowing the nail to grow out so it may be trimmed properly. Infection may be somewhat difficult to prevent in cleaning and treating ingrown nails due to the warm, dark, and damp environment in people's shoes. Peroxide is immediately effective to help clean minor infections but iodine is more effective in the long term as it continues to prevent bacterial growth even after it is dry. Iodine should not be used on deep wounds. In such cases a physician or podiatrist should be consulted.
Phenolization This is the method of choice. (1,2,3)
Following injection of a local anaesthetic at the basis of the toenail and application of a tourniquet, the surgeon will remove the edge of the nail growing into the flesh and cauterize the matrix area with phenol to permanently and selectively destroy the matrix manufacturing the ingrown portion of the nail. Advantages: the surgery can be performed in the doctor's private practice under local anaesthesia, little or no pain following the intervention, no need to stop work, no visible scar. Disadvantages: the procedure will fail in about 2 to 3 times out of one hundred.
Wedge Resection Partial removal of the nail or an offending piece of nail. More complex than a complete nail avulsion (removal).
More severe cases, such as when the area around the nail becomes infected or the nail will not grow back properly, must be treated by a professional. In these cases, the digit is first injected with a common local anesthetic. After the area is numb, the physician will perform an onychotomy in which he or she cuts away the nail along the edge that is growing into the skin and pulls out the piece of nail. After the nail is removed, the nailbed is often cauterised or chemically burnt to prevent nail regrowth. In some cases they may also surgically drain the infection. This process is referred to as a "wedge resection". The entire procedure may be performed in a standard doctor's office and takes approximately thirty to forty-five minutes depending on the extent of the problem. The patient is allowed to go home immediately and the recovery time is anywhere from a few days to a week barring any complications such as infection. As a followup, a physician may prescribe an oral or topical antibiotic or a special soak to be used for approximately a week after the surgery.
CO2 Laser surgery
Following injection of a local anaesthetic at the basis of the toe and application of a small tourniquet, the surgeon will remove the edge of nail growing into the flesh. He will then permanently destroy the portion manufacturing the ingrown nail by laser photocoagulation. Stitches are necessary. Disadvantages: post-operative pain due to the wound and scar.
Nail Avulsion (Removal) Complete removal of whole nail.
While in some similar cases patients may wish to have the offending nail completely removed, this procedure is not recommended by nail experts because the postoperative period is long and painful. Furthermore, complete removal of whole nail does not prevent from recurrences (2,3).
Complete removal of whole nail is much like the one above, in which anaesthetic is injected, the nail is removed quickly and painlessly and the patient can leave immediately. The entire procedure can be performed in around 10 minutes and is much less complex than a "wedge resection" as above. The nail is able to grow back although in most cases it will cause further problems as it can become ingrown very easily. In many cases the nail matrix is coated with a chemical so no nail will ever grow back. As you can see from the images below, the nail-less toe looks much like a normal toe and fake nails or nail varnish can still be applied to the area.
"Ingrown nail"