Health Matters

New treatments for ingrown toenails

Conway McLean, DPM, Journal columnist

Sandra, a tall, athletic 14 year old, was thought to have escaped the family curse until she started playing basketball on the team. Not long after starting practices, she began to experience an obvious throbbing pain from her big toes, after all the running and jumping involved in a typical after-school session. Like her mother and her sister, who had battled with it for years, she was now experiencing the dreaded ingrown nail.

In contrast is Tom, a young man who recently joined the work force after graduating from school. Tom had a nasty habit of trimming his toenails rather aggressively, regularly drawing blood during his attempts at bathroom surgery. Clearly, his technique left something to be desired since he consistently noted a sharp pain from his toes when at work where he has to move heavy boxes.

Then there is Barbara, a 60 year old businesswoman, successful and driven. Looking good is a requirement of her position and that meant wearing fashionable shoes. Unlike many women, she had historically found these comfortable until she hit her fifties when she began noticing a gradual but insidious change in the shape of her big toenails. They started curving more, digging into her big toes, mostly when wearing her dress shoes. Work had become both painstaking and painful.

William is a senior citizen, well into retirement. Staying active is important to him and his daily hike is his favorite form of exercise. Unfortunately, pain was making that difficult. His nails had become yellowed and thick, curving into his toe at the same time. Any shoe pressure was pushing his nail into the toe, causing pain during his daily walk. Regrettably, this was becoming a recurrent reason not to walk and that wouldn’t do at all.

These are just a few of the many reasons an individual can experience pain from the nail area. These all have in common the fact that the nail, a hard, unyielding object, was poking them and causing pain. It seems such a simple condition. Shouldn’t there be an easy solution? There is, but many Americans never learn of better treatments. Too often, they resort to the usual attempts at self-surgery in their bathroom “operatory.” Commonly, these attempts lead to worsening of the problem, even the development of an infection.

The nail unit (all the structures in and around the nail itself) possesses obvious nooks and crannies, like the groove along the side of the nail, which is covered by skin. These regions are impossible to clean and so generally harbor various microorganisms. When the nail edge pressures the fold of skin sufficiently, an opening in the skin can be created, allowing germs entry to the soft tissues. This can lead to infection. In a young person, there are few ramifications beyond localized swelling, pain, or pus.

In contrast is the immune-compromised individual, like those with diabetes. The simple ingrown nail can lead to serious problems, even amputation. Because diabetes results in impaired immune function, any infection can have dire consequences. Adding to this is the gradual loss of nerve function (neuropathy) that occurs with this ubiquitous disease. The diabetic with some neuropathy often won’t perceive pain from an infection and so will do nothing. Ingrown nails have led to too many amputations, an unnecessary consequence.

Symptomatic ingrown nails are most common in the second and fifth decades of life, although they can occur at most any age. The distribution of sensory nerves is high in the toe, almost as much as the fingers, so this can be a painful condition. There are some long term repercussions, although rare in the healthy individual with good blood flow and a functioning immune system.

Surprisingly, the use of antibiotics is rarely necessary. In the face of impaired immunity or poor arterial flow, unusual measures, like antibiotics, may be prudent. But the crux of the problem is that this unyielding object is sticking the sufferer in the toe. If you step on a tack and you want it to get better, you’d probably should take the tack out. It continues to amaze me how quickly these resolve when the “offending” edge of nail is removed. Painful nails, ongoing for months, healed in a few days.

Nail edge removal need not be a painful process, when appropriate measures are taken. Obviously, the affected digit needs to be anesthetized but this is made comfortable with the use of a numbing spray. Most of the “sensitive” nerves are in the skin so this makes a significant difference in comfort.

What about when this is a problem of the shape of one’s nail? Trimming of the nail can help, but that won’t change the shape of the nail as it grows. And, by and large, nail problems go one way: they get worse, from fungal infections to the dreaded pincer nail.

Various techniques have been utilized over the years to eradicate some portion of the nail root. This is the structure responsible for growing the actual nail plate. Although we don’t have the ability to straighten out a misshapen nail root, we can remove some of it and make it so that portion of nail never grows back. When done successfully, it means pretty much permanent resolution of the ingrown nail pain.

It gets interesting when examining how many different ways this goal, complete removal of some or all of the nail root, can be achieved. Although rarely performed these days (we hope), the surgical removal of the edges of this structure, with a scalpel, has been one method of achieving this. Not only is healing a bit of a nightmare, the results, eventually, are often disfiguring. Even lasers have been used but this is mostly marketing since typical office lasers (CO2) haven’t proven reliable for this procedure and something additional must be used.

By far the most common method of narrowing the nail is with application of an acid, which has the effect of burning whatever it comes in contact with. Consequently, healing is often slow and messy, with recurrence of the treated nail common. A well-established method of soft tissue surgery, radio-waves provide tremendous benefits in nail surgery. With this technology, no tissue is burned, resulting in shorter healing times. Also important, the success rate is extremely high, meaning the edge almost never grows back.

It’s easy to ignore these kinds of health conditions, disabling they are not. But when they are recurrent or lasting, they interfere with one’s quality of life. Any chronic cause of pain is going to add to your stress levels and that isn’t healthy. There are some simple home treatments that can help, but when they fail, seek out a specialist who should use the most effective and least painful techniques. Don’t live with pain: it’s bad for health and happiness!

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula. Dr. McLean’s practice, Superior Foot and Ankle Centers, has offices in Marquette and Escanaba, and now the Keweenaw following the recent addition of an office in L’Anse. McLean has lectured internationally, and written dozens of articles on wound care, surgery, and diabetic foot medicine. He is board certified in surgery, wound care and lower extremity biomechanics.


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