Ingrown toenails are the painful process in which the corners of the nail will impinge the adjacent flesh. Oftentimes this results in a paronychia infection. The toenail edge penetrates the adjacent skin edge and causes an infectious reaction. Infection begins as mild redness, or erythema, and progresses rapidly to puss or purulence. Granulation tissue may also develop. This takes the form of a bleeding, painful hypertrophy of skin and is the result of an infectious process. The toenails become very painful and irritated in shoe gear. Often leaving socks stained with drainage from the infection. If left untreated it can quickly penetrate to the level of the bone causing an osteomyelitis, or infection in the bone. Ingrown toenail edges develop for a variety of reasons. Sometimes it is hereditary and patients will note that prior family members have also had this condition. Other times it is related to a prior history of trauma which has changed the nail growth pattern causing recurrent ingrown nail edges. Long term use of certain medications can also contribute to a permanent change in the nail shape. Development of onychomycosis, a thick yellow fungus infection, can also change the nail integrity making it more prone to causing a paronychia. In any event, the process occurs quickly and rapidly progressing into an infection. Treatment for an ingrown nail usually first begins with the patient trying to pick the nail edge out of the flesh themselves. This usually does not work and the patient should seek the advice of a podiatrist. Most often this technique will cause more aggravation of the already inflamed tissue and expedite the process of infection. The nail edge must be removed from the flesh so that the process of healing can begin. This is done with a local anesthetic nerve block to the toe that is affected. Once the toe is anesthetized a partial nail avulsion is performed. The nail is split from its tip and removed from its base in the corner affected, or sometimes the entire toenail plate is removed. This allows the tissue to recover and your body to begin the healing process, many times without using oral antibiotics. Oral and topical antibiotics alone usually do not resolve this condition because the nail is still penetrated through the flesh, creating an opening in the skin which is your body's natural protective barrier. It is not much different than having a foreign body reaction with a splinter or other object which penetrates your natural skin barrier. If enough of the nail was not removed the infection cannot resolve because it keeps the skin open. This is why self treatment usually does not work. The toe really needs to be anesthetized so that the correct amount of toenail can be removed to allow the surrounding flesh to heal. Most other breaks in the skin barrier heal with self treatment because there is no nail edge preventing the skin from healing. Postoperative treatment for the procedure usually involves a topical antibiotic bandage daily and washing the toe regularly. Bandaging can stop when there is no drainage or stain on the bandage. Improvement should be noted on a daily basis. If the infection progresses then oral antibiotics may be needed. When healing is completed the patient can usually resume all activity and shoe gear. Within 7-8 months of having the nail avulsion the nail may grow in the same path from which it was removed. Much like hair curls after they are cut, the nail may grow in the same direction which had originally caused the infection. Around this time the patient will usually start to feel the beginnings of some pain. If this occurs then the patient should return to the podiatrist before infection recurs. A permanent solution for this recurrent ingrown nail edge is a matrixectomy procedure. Once again, the toe is anesthetized and the toenail edge is removed in much the same manner as when it was infected. If there is no infection present, then the nail matrix tissue (which is where the nail growth is originated from) can be cauterized. This is done with several different techniques including laser or acid. Sometimes it can be surgically removed. It has a very successful cure rate for preventing that corner of the nail from growing back. This is recommended if a patient begins to experience multiple paronychia infections or pain from recurring ingrown nail edges. Postoperative treatment for this procedure involves the same as the infected toenail procedure with the exception that it takes a little longer to heal. 7-8 months after this procedure, the corner of the toenail should not take the same path which caused the infection. Complications to these procedures can be irregular or unpredictable nail growth patterns. This includes possibly cauterizing too much of the nail matrix, resulting in a more narrow nail than desired. More severe complications could result in an infection which could progress to a bone infection. Fortunately these complications are rare and the procedures described above have a very high success rate.
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