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Ingrown Toenail

An ingrown toenail (onychocryptosis) occurs when part of the nail penetrates the skin, which can often result in an infection. The ingrown nail can also apply pressure in the nail fold area without penetrating the skin - this is not technically an ingrown toe nail, but can also be painful (a corn/callus is also common down the side of the nail and is a reaction to this pressure, rather than the nail actually penetrating the skin).

What does an ingrown toe nail (onychocryptosis) look like:
Usually the side of the nail penetrates deep and it is difficult to see the edge of the nail. The severity of appearance of the nail will vary. Some will just have a nail that appears deeply embedded down the side or sides of the nail. In some the corner or a small spike of nail may penetrate the skin, just like a knife. This can result in an infection and the development of proud flesh (granulation tissue). The toe will then be red, inflamed and painful.

What are the symptoms of in ingrown toenail (onychocryptosis):
Pain is the main symptom of an ingrown toe nail - usually just starting as some minor discomfort. This may be just the pressure from the side of the nail or it may be because the nail has actually penetrated the skin down the side of the nail. The toe is not necessarily infected, but this can develop after the nail penetrate the skin to become ingrown. The infection can spread, making the toe red and inflamed (paronychia). A collection of pus may also develop.

What causes an ingrown nail (onychocryptosis):
Poor cutting of the nail is most commonly blamed as being the cause of an ingrown toe nail, but this is not necessarily the case. The following factors are involved in the cause of ingrown toenails (onychocryptosis):

  • the primary risk factor is the shape of the nail - a nail that is more curved from side to side rather than being flat is more likely to become an ingrown nail (incurvated nails). Some nails go down the side into the nail fold area for a relatively large distance. A large portion of the nail is almost vertical rather than being horizontal. The most severe of these types of nail is called a 'pincer nail' in which both side of the nail are very curved. The shape of the nail is usually inherited (congenital), but it can be influenced by trauma and/or shoe pressure.
  • poor cutting of these types of nails can leave a sharp corner (or if worse, a small spike) that will initially cause symptoms by putting pressure on the skin and then later penetrate the skin. Trimming too far down the sides is a common cause of an ingrown toe nail.
  • footwear that is tighter is more likely to increase pressure between the skin in the nail fold and nail, increasing the risk on an ingrown nail.
  • previous trauma to the nail may alter the shape of the nail, making it more prone to becoming an ingrown nail
  • pressure from the toe next to the nail that has ingrown can sometime be a factor
  • a 'chubby' or fleshy toe is more likely to have a nail grow into it. Those whose feet swell are a lot are more prone to having this happen.

Self treatment of the ingrown nail (onychocryptosis):
The cornerstone of self treatment and prevention of ingrown toe nails involves cutting the nail straight across to allow the corners to protrude, so that they do not penetrate the skin. Cut the toe nails straight across without tapering the corners. However, this can be difficult if the nail is very curved down the side. In this case DO NOT 'dig' down the sides - seek professional help for this (see below).
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.
Avoid wearing shoes and socks that are too tight.
Keep feet clean to prevent the ingrown nail from becoming infected.
Those with poor circulation or diabetes should not do any self management of ingrown toenails but see a Podiatrist.
Podiatric treatment of the ingrown nail (onychocryptosis):
Regular treatment by a Podiatrist can often be needed, as a conservative approach to prevent the nail becoming a problem is can be recommended.
Initial treatment of the ingrown nail (onychocryptosis):

  • Antibiotics are often used to treat the infected ingrown toenail, but don't forget that the cause of the infected (the ingrown nail) is still there, so there is not a lot of point in treating the infection while the cause remains. Sometimes antibiotics are used to help the infection clear after the nail has been removed.
  • A skilled Podiatrist can easily remove the corner or spike that has penetrated the skin, often with relatively little discomfort. If the ingrown nail is too painful, a local anesthetic may be needed to do this. Don't forget that unless the offending piece of nail that is causing the ingrown toe nail is removed, the infection is likely to persist.
  • After this some antiseptic dressing for a few days is all that is needed to clear up the infection, especially if you are healthy and have no healing problems. Antibiotics and/or prolonged period of dressings are needed, especially if there is a problem with wound healing or if the circulation is poor or if you have diabetes.
  • Occasionally, after the above treatment if the pain persist - this may be due to there being another spike of nail deeper down causing the ingrown toenail.

Ongoing treatment of the ingrown toenail (onychocryptosis):

  • Ingrown toe nails have a great tendency to happen again. They happen in the first place because of a number of reasons - the most common of those reasons is the shape to the nail. Generally, this is if the nail is curved down the side. With good self treatment (see above), it may be possible to prevent it reoccurring.

Surgical treatment of the ingrown toenail (onychocryptosis):

  • if the ingrown nail is severe, or if conservative care is difficult, or if the ingrown toenail does not respond well to conservative care, then minor surgical intervention is a good option. Minor surgery is a relatively simple procedure and is very successful for long term relief that is permanent.
  • a number of different minor surgical procedures can be used by a Podiatrist to treat an ingrown toe nail. Almost all of these are done in the office under a local anesthetic.
  • the most common procedure is the removal of a portion of the nail down the side of the nail that is causing the problem. In the worst case of a total nail which is curved, it may be necessary to remove the entire nail.
  • After a nail or part of the nail is removed, it will grow back as the growing cells at the base of the nail are still there, unless something is done to remove them. Most commonly an acid is used to destroy the growing cells to prevent regrowth. Other options to prevent it growing back include, surgically debriding the growing area or using a laser. For some reason a few percent do reoccur.
  • Generally, after the surgery you will need to keep your foot elevated for a few hours and rest is advisable. The following day, you can return to work or school. It is advisable not to take part in vigorous activities, such as running for 2 weeks after the surgery. The use of an open toe shoe, so that there is no pressure on the area also facilitates healing.