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Getting a toehold on ingrown nails


While many dermatologists avoid ingrown toenails because they can be time-consuming and difficult to treat, one expert says simpler procedures and effective staff training can maximize one's efficiency.

Kona Island, Hawaii - To make nail surgeries as quick and safe as possible, one expert recommends keeping procedures simple and the staff well-trained.

Because treating ingrown toenails can be time-consuming, "Most physicians, including many dermatologists, don't want to deal with them," says C. Ralph Daniel, M.D., clinical professor of dermatology, University of Mississippi Medical Center, Jackson, Miss.

"Many medical dermatologists choose not to do surgery; some surgical dermatologists might choose to do procedures that would have higher reimbursement rates and leave the ingrown toenails to those who more frequently treat this problem," he explains.

In ingrown toenails, Dr. Daniel tells Dermatology Times, "The nail plate grows into the surrounding soft tissue structures. When that happens, there is a splinter or foreign-body reaction - the body tries to expel it," as evidenced through an inflammatory response that can include granulation tissue swelling.

Sometimes, he notes, a secondary infection occurs, which also must be treated.

Predisposing factors for ingrown toenails include genetic factors, wide feet and trimming nails incorrectly.

"They should be cut straight across, not rounded at the edges," Dr. Daniel says.

Additionally, he says orthopedic problems such as supination and pronation, as well as high-heeled and/or narrow-toed shoes, can create pressure that results in ingrown toenails. In these areas, Dr. Daniel says patient education can help prevent problems.

To cut or not to cut

Treatments for ingrown toenails range from nonsurgical to surgical.

When a patient presents with a very early ingrown toenail, Dr. Daniel explains, treatment can involve 20 percent to 50 percent urea applied to the nail plate once or twice daily.

"To decrease the rigidity of the nail plate, which therefore decreases the splinter effect, one also can use cold soaks" with ice and water for five minutes three or four times daily for one to two weeks, he adds.

In contrast, Dr. Daniel cautions that warm soaks could increase inflammation in this case.

If an early stage ingrown toenail presents with inflammation, he says, "One can apply a medium to higher-potency topical steroid after each soak for approximately one week."

Another technique for treating early ingrown toenails involves teaching an assistant to place wisps of cotton underneath the ingrown part of the nail plate to lift it out, Dr. Daniel says. One also might place dental floss for similar effect (J Am Acad Dermatol. 2004;50:939-940), he adds. One researcher also has recommended using tape to pull the nailfold away from the area of ingrowth (Int J Dermatol. 2004;43:759-765).

For more severe ingrown toenails, surgical options include anesthetizing the nail before cutting out the nail plate using an English anvil nail splitter, Dr. Daniel says. After this procedure, he suggests using a chemical nail matrixectomy on the side that's ingrown to decrease the chance of recurrence. This procedure decreases the nail matrix's ability to make the nail plate in the area of ingrowth, Dr. Daniel explains.

He says he uses the chemical matrixectomy method most frequently because it's relatively simple and doesn't require specialized knowledge or experience.

With this procedure, Dr. Daniel says, "One just cuts out the offending part of the nail plate and applies a chemical" to the portion of the nail matrix that created it.

Solutions used for chemical nail matrixectomies include 88 percent phenol or 10 percent sodium hydroxide, he says.

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