II. Epidemiology

  1. Unilateral in 80% of cases
  2. Usually affects hallux (great toe)

III. Risk Factors

  1. Improper nail cutting (nail incurves into nail fold)
  2. Poorly fitting shoes, especially if constrictive (callus forms in nail fold)
  3. Impaired nail self-care
  4. Obesity
  5. Hyperhidrosis
  6. Foot Trauma
  7. Altered gait
  8. Congenital disorders
    1. Pachyonychia congenita
    2. Trisomy 13
    3. Unna-Thost Syndrome
  9. Comorbid conditions
    1. Pityriasis
    2. Hyperthyroidism
    3. Diabetes Mellitus (Dystrophic Nails)
    4. Acromegaly

IV. Signs: Ingrown Toenail

  1. Stage 1 Ingrown Nail
    1. Erythema, trace edema and pain at lateral nail fold
  2. Stage 2 Ingrown Nail
    1. Increased pain and foul discharge from nail edge
    2. Signs of Bacterial Paronychia
  3. Stage 3 Ingrown Nail
    1. Most significant symptoms of Ingrown Nail
    2. Lateral nail fold hypertrophy and chronic granulation tissue

V. Management: Non-surgical (mild cases with minimal pain or erythema)

  1. Expect resolution over 2-12 weeks
  2. Warm soapy water soaks for 15-20 minutes nightly and
  3. Raise lateral nail margins
    1. Insert cotton-wisp or dental floss under nail at Ingrown Nail groove edge or
    2. Use intravenous drip tubing as an improvised gutter splint
      1. Split intravenous drip tubing lengthwise, so can be inserted over the nail edge
      2. Tape, glue (cyanoacrylate) or wound-closure strips in place
      3. Arai (2004) In J Dermatol 43(10):759-65 [PubMed]
  4. Adjunctive
    1. Apply Corticosteroid cream or ointment to the affected area three times daily for 2-14 days
    2. Apply topical antibiotic (bacitacin) and/or Corticosteroid to ingrown margin twice daily
  5. General measures
    1. Wear shoes with open toe or with wide toe box
    2. Manage Hyperhydrosis
    3. Treat Onychomycosis

VI. Management: Antibiotics

  1. Not routinely recommended
  2. Has been used when matrix destruction is performed but without good evidence
  3. Paronychia may be the only indication for systemic antibiotics

VII. Management: Surgical Nail Avulsion (moderate to severe pain, inflammation, purulent drainage)

VIII. Complications

  1. Bacterial Paronychia
    1. Treat Paronychia with antibiotics if present
  2. Onychogryposis
    1. Hypertrophic shape changes of nail

IX. Prevention

  1. Trim nail flat (not too short, not rounded, not V-Shaped)

X. References

  1. Mandracchia (July, 1998) Hospital Medicine, p. 36-43
  2. Peggs in Pfenninger (1994) Procedures, Mosby, p. 28-43
  3. Mayeaux (2019) Am Fam Physician 100(3): 158-64 [PubMed]
  4. Heidelbaugh (2009) Am Fam Physician 79(4): 303-12 [PubMed]
  5. Zuber (2002) Am Fam Physician 65(2):2547-58 [PubMed]

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