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Onychocryptosis

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Other Names

  • Ingrown Toenail
  • Unguis Incarnates
  • Onychocryptosis

Background

  • This page refers to Onychocryptosis, more commonly referred to as an 'Ingrown Toenail'

History

Epidemiology

  • Overall, the epidemiology is not well reported in the literature
    • Likely in part because mild cases often do not seek medical treatment
  • Demographics
    • Thought to be bimodal, presenting in-between 1st and 3rd decade and then in elderly patients
  • Prevalence
    • Likely the most common nail problem encountered in general practice, dermatology (need citation)
    • One study found 40% of 21 year olds with nail disorders had onychocryptosis[1]
    • A Spanish study found the prevalence was 15.7% in a podiatry population, average age 54[2]
    • In the general population, prevalence ranges from 2.5%-5%[3]

Pathophysiology

Illustration of the fingernail anatomy[4]
  • General
    • Characterized by penetration of the periungual dermis by its contiguous nail plate
    • Often results in a cascade of foreign body, inflammatory, infectious, and reparative processes
    • If untreated, it can cause considerable pain, discomfort, and disability
  • Location
    • Great toe represents 70% of cases, likely related to increased stress during ambulation

Etiology

  • Improper nail trimming
    • Appears to be the most common etiology
    • May lead to a nail spike that traumatizes adjacent soft tissue
  • Excess of skin surrounding the nail
    • Wide lateral tissue tending to bulge up around the nail leading to pressure and necrosis[5]
  • Nail plate edge grows into the overlapping lateral nail fold

Risk Factors

Examples of improper and proper toenail trimming. Toenails should be cut straight across, and the corners should not be rounded off.[6]
  • Demographic
    • Advanced age
    • Caucasian[7]
    • Individuals earning less than 100,000
    • Residents of southern US
  • Systemic
  • Podiatric
    • Improper nail trimming technique[1]
    • Onychotillomania
    • Trauma[3]
    • History of nail surgery
    • Constricting footwear
    • Bony abnormalities
    • Onychomycosis
    • Second toe length equal to or greater than their ipsilateral hallux
  • Nail dysfunction (controversial)
    • Pincer-nail deformity
    • Wide nail plates
    • Congenital malalignment of the toenails
    • Thickening of the nail plate
  • Medications
    • Epidermal growth factor receptor inhibitors (gefitinib, cetuximab)
    • Protease inhibitors (Indinavir, Ritonavir))
    • Retinoids
    • Docetaxel
    • Cyclosporine
    • Oral antifungals (name?)
  • Protective (reduced risk)
    • Barefoot populations[8]

Differential Diagnosis


Clinical Features

  • History
    • Diagnosis is generally straight forward
    • Most patients will present with toe pain
    • Inquire about chronology, prior trauma, footwear, occupation, sports activities, and hobbies
    • Assess pain at rest, standing, and ambulating.
  • Physical Exam: Physical Exam Foot
    • Nail polish should be removed to facilitate a complete examination
    • Nails are also evaluated with the patient upright and during the gait
    • Stage 1: signs of inflammation in the affected toe: pain, swelling, and erythema
    • Stage 2: acute infection with seropurulent drainage, ulceration of the nail fold, causing more edema and tenderness
    • Stage 3: Hypertrophic granulation tissue, increases compression, swelling and discharge
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Foot
    • Not necessary to make diagnosis
    • Can help identify risk factors, contributing biomechanical dysfunction
    • Specifically, useful to exclude benign and malignant growths of the toes

Classification

  • Mild (Stage I)
    • Nail fold swelling, edema, erythema
    • Pain exacerbated by pressure
  • Moderate (Stage II)
    • Stage I features coupled with an active or acute infection
    • Presents as granulation tissue, seropurulent discharge, or ulceration of the nail fold
  • Severe (Stage III)
    • Chronic inflammation with formation of epithelialized granulation tissue
    • Marked nail fold hypertrophy

Management

Gutter splint treatment for ingrown toenails.[6]

Nonoperative

  • Indications
    • Stage I disease
    • Can attempt in stage II, III but will often require surgery
  • Goals
    • Relieve symptoms
    • Prevent the ingrown toenail from worsening
    • Address the underlying problem
    • prevent recurrences
  • Address underlying etiology
    • E.g. systemic disease (diabetes, obesity), local (nail abnormalities, onychomycosis, subungual neoplasms, etc)
    • Medications (indinavir, ritonavir, retinoids, docetaxel, cyclosporine, and oral antifungals)
  • Suitable footwear
    • Encourage use of “wide toe box” or “open toe” shoes
    • Avoid high heeled or pointy shoes that are too narrow
    • Suitable support (cushioning, laces) to prevent feet sliding forward and being compressed by the front of the shoe
  • Taping
    • Goal: separate the nail fold from the offending nail edge[9]
    • Basic: daily application pulling the offending nail fold away from the nail plate in oblique and proximal directions
    • Additional securing: consider cyanoacrylate adhesive, acetone, mastisol, and a second anchoring tape
  • Cotton Packing
    • Daily home-insertion of a cotton wisp, sometimes soaked with antiseptic, between the corner of the nail plate and the nail fold
    • Over time, more cotton inserted until sufficient separation is achieved to mitigate symptoms[10]
    • Alternative: “rolled cotton padding” or “cotton-nail cast” with cyanoacrylate can be applied in the office, left in place for up to 2 months
    • Efficacious in treating stage I, II, and III patients[11]
  • Gutter Packing
    • Description: use of a sterile plastic tube (from IV drip, butterfly needle) with a vertical slit that is inserted into the nail groove
    • One study using acrylic resin (N=106) had a 100% cure rate, even for more severe stages[12]
  • Proper nail cutting technique education
    • Counsel patient to trim toenails by cutting straight across the nail plate without rounding the edges
    • Incorrectly rounding off the nail plate corners promotes barbs or spicules that may anchor into the periungual soft tissue
  • Orthonyxia
    • Nail correction, performed to rectify nail overcurvature using nail brace or elastic wiring
    • One study found compared to partial matrix excision, resulted in significant improvement<Kruijff S, van Det RJ, van der Meer GT, et al. Partial matrix excision or orthonyxia for ingrowing toenails. J Am Coll Surg. 2008;206:148- 53. [PMID: 18155581].</ref>
  • Warm soaks
    • Soaks for 10 to 20 minutes daily in warm, soapy water often provides symptomatic relief.
    • Hydrogen peroxide and iodine can be used for cleaning
  • Topical medications
    • Generally considered controversial, clinical trial data is lacking
    • Antibiotics and steroids are suggested in some of the literature
    • Silver nitrate may decrease inflammation and expedite healing
  • Custom Orthotics
  • Podiatry Referral

Operative

  • Indications
    • Failure of conservative management, especially in stage II or III
    • Recurrence
    • Significant infection
  • Technique
    • Partial nail avulsion
    • Matricectomy
    • Vandenbos procedure
    • Zadik technique
    • Winograd procedure

Rehab and Return to Play

Rehabilitation

  • No specific rehabilitation plan

Return to Play/ Work

  • Most athletes can continue to play if symptoms are mild or moderate
  • Following removal or surgery
    • May require 1-2 weeks after procedure before beginning a gradual return to play
  • Most individuals can return to work the next day following treatment

Complications and Prognosis

Prognosis

  • Surgical management
    • Cochrane systematic review: surgical interventions more effective in preventing recurrence, especially when coupled with phenol application[13]

Complications

  • Unknown

See Also


References

  1. 1.0 1.1 Pico AM, Verjano E, Mayordomo R. Relation Between Nail Consistency and Incidence of Ingrown Toenails in Young Male Runners. J Am Podiatr Med Assoc. 2017;107:137-43. [PMID: 28394683].
  2. Mosquera-Fernandez A, Diaz-Rodriguez M, Gonzalez-Martin C, et al. Habitos podologicos en personas con alteraciones ungueales. Gac Med Mex. 2017;153:810-7. [PMID: 29414977].
  3. 3.0 3.1 Vural S, Bostanci S, Kocyigit P, et al. Risk Factors and Frequency of Ingrown Nails in Adult Diabetic Patients. J Foot Ankle Surg. 2018;57:289-95. [PMID: 29329712].
  4. Patel L. Management of Simple Nail Bed Lacerations and Subungual Hematomas in the Emergency Department. Pediatric Emergency Care. 2014; 30 (10): 742-745. doi: 10.1097/PEC.0000000000000241.
  5. Khunger N, Kandhari R. Ingrown toenails. Indian J Dermatol Venereol Leprol. 2012 May-Jun;78(3):279-89
  6. 6.0 6.1 Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician. 2009;79(4):303.
  7. DeLauro NM, DeLauro TM. Onychocryptosis. Clin Podiatr Med Surg. 2004;21:617-30. [PMID: 15450901].
  8. Gunal I, Kosay C, Veziroglu A, et al. Relationship between onychocryptosis and foot type and treatment with toe spacer. A preliminary investigation. J Am Podiatr Med Assoc. 2003;93:33-6. [PMID: 12533554].
  9. Manca D. Practice tips. Taping toes. Effective treatment for ingrown toenails. Can Fam Physician. 1998;44:275. [PMID: 9512830].
  10. Senapati A. Conservative outpatient management of ingrowing toenails. J R Soc Med. 1986;79:339-40. [PMID: 3723536].
  11. Du JF, Xi XY, Liu ZH. Successful conservative treatment with cotton wisp for ingrown toenail with granulation. Dermatol Ther. 2016;29:486-7. [PMID: 27543365].
  12. Taheri A, Mansoori P, Alinia H, et al. A conservative method to gutter splint ingrown toenails. JAMA Dermatol. 2014;150:1359-60. [PMID: 25188750].
  13. Eekhof JA, Van Wijk B, Knuistingh Neven A, van der Wouden JC. Interventions for ingrowing toenails. Cochrane Database Syst Rev. 2012;Cd001541. [PMID: 22513901].
Created by:
John Kiel on 16 February 2022 05:30:36
Authors:
Last edited:
4 October 2022 12:44:02
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