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Dangers of the ingrown nail

Conway McLean, DPM

Medicine provides for so many fascinating topics, from basic human anatomy to some bizarre medical condition. Some diseases are so strange we can’t help but be intrigued. But what about the mundane that affects so many of us at one time or another? Certainly an obvious candidate would be the common cold, a malady everyone has experienced. Can you think of another affliction, almost as frequently experienced? One candidate would be the dreaded ingrown nail.

Sounds quite benign, doesn’t it? A source of minor annoyance to many, an ingrown nail can develop due to a great variety of reasons. And though many experience only mild pain from one of these, for some people, there are real and potentially dangerous repercussions. How to know the difference? Much of it depends on your general health.

As an example, I present to you the story of Sue, a middle-aged, mildly overweight woman and a well-controlled diabetic. Sue worked on her feet as a cashier and had for years. Sue had been diagnosed with diabetes just a few years ago, and had experienced no real difficulties with the condition. She took her pills and tried, not terribly consistently, to eat well. Sue was not worried about her toenails, even though they were rather misshapen and discolored, but caused her no pain. They were extremely curved, but she vaguely assumed they had pretty much always been that way.

The first time there was an indication something was amiss was the day she noticed some drainage on her sock. Not terribly alarming, the toe did look a little red and swollen, although she had no discomfort from it. Hard to take the problem too seriously if it didn’t bother her. In the days to follow, she thought little of it. When she looked again, the toe seemed a bit more swollen and redder, but still was not painful. She decided on a “wait and see” attitude.

It wasn’t until she had difficulty fitting into her shoe that she became concerned. A more thorough examination revealed a very red, swollen big toe, especially around the “simple” ingrown nail edge. The swelling continued up onto the foot with some discoloration extending toward the arch. The toe felt stiff and somehow tight but, again, minimal actual pain was noted. Sue had heard that people with diabetes can have bad foot problems but, since had not been given any specific information about it, she did not know much. It seemed wise at this point to make an appointment with her family doctor. Unfortunately, when talking to the receptionist at her PCP’s office, she apparently downplayed the problem since her appointment was not made for a week.

By the time of this visit, her whole foot was swollen and red. She was now wearing her husband’s sneaker since she didn’t fit into hers. Her doctor took one look at the foot and directed her immediately to the emergency room. There she was seen, eventually, by the ER doctor who was not quite sure what to make of it. X-rays were taken demonstrating some of the definitive changes of a bone infection. A general surgeon, who was on-call, consulted on the case and declared an amputation was necessary. She was told this condition was potentially life-threatening and the amp was a necessity. Just like that, she was an amputee.

Sue was never educated about the problems that go along with diabetes, like the neuropathy which makes it difficult to “feel” things appropriately. She was unaware, as are too many with this condition, she had lost “the gift of pain.” Simply getting educated about diabetic foot care could have prevented this tragic outcome. No one is suggesting that most individuals who develop an ingrown nail will suffer limb loss as a result. To the young, ingrown nails are a nuisance, but can make physical pursuits, like most sports, very uncomfortable.

It is not uncommon for an ingrown nail to allow bacterial invasion into the toe. This is common since the nail unit is a wonderful place for bacteria to hang out, protected as they are. Typically, these organisms are not causing an infection, which would imply the microbes have invaded the soft tissue of the toe and are reproducing. In a younger person, with the vitality of youth on their side, a fully functioning immune system hard at work, these infections rarely spread.

Not truly an ingrown nail, one complication of this misshapen nail is an ulcer developing underneath the nail plate. Any nail which is curved or irregular can wear on the skin beneath the plate and lead to a small ulcer. These are surprisingly common in the elderly who have developed a contorted nail and typically have less than optimal arterial blood flow. Once again, this means there is an opening in that all-important barrier to infection: skin.

Similar to diabetics, for those with PAD, peripheral arterial disease, an ingrown nail can again have serious complications. Blood is essential to all living tissue, and any cell deprived of oxygen and critical nutrients will become, in essence, weak and unhealthy. Depending on the severity of the impaired blood flow, any trauma at all can lead to an end-stage complication: gangrene. A bacterial infection resulting from an ingrown nail certainly qualifies.

What actually is an ingrown nail? Actually, this is a difficult question, and the answer depends on who is responding. For many health care providers, any nail causing pressuring to the skin and soft tissues in the groove the nail resides in, on each side of the nail plate, is an ingrown nail. Often this is due to a nail that has become more curved over time, a common development. Many other possibilities occur, like an arch that rolls excessively, pushing the skin into the nail. The result is the same, although the cause can be drastically different. How about a pair of shoes that are too tight? There are a multitude of reasons.

As to treatment, too frequently an antibiotic will be prescribed. Numerous studies have clearly demonstrated this is unnecessary since the body’s natural defenses will be more than sufficient if allowed to work. In this case, the “best antibiotic is cold steel,” meaning a minor procedure whereby the entire edge of nail is removed allowing drainage of the infection and markedly improved blood flow to the area. As you may have guessed, anesthetizing the toe is a requirement for this to be performed comfortably.

When someone has recurrent ingrown nails, altering the shape of the nail is the best solution. The edge of the nail root, the structure growing that part of the nail, is somehow removed. But some ways are better than others, with most health care providers using a potent acid. Obviously, this means a chemical burn is intentionally created. These are slow to heal, painful and have a poor success rate, meaning the edge often grows back. Much less destructive is the use of high-intensity radiowaves, which don’t burn tissue. Healing is significantly faster and the success rate is exceptional.

In summary, hopefully readers who are elderly or diabetic will take this common problem more seriously. It can lead to some serious complications. In contrast, to the young and healthy, ingrown nails are simply a pain in the … toe! But suffering is unnecessary. Temporary removal of the edge of the nail can be achieved simply and comfortably by the appropriate health professional. And when there is recurrence, a permanent solution is easily and reliably obtained. So don’t suffer: you need to keep moving. Our bodies were made to move!

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.