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Pediatrics: General Medicine > Dermatology
Ingrown Nails
Article Last Updated: Jul 19, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Ann G Egland, MD, Consulting Staff, Department of Operational and Emergency Medicine, Walter Reed Army Medical Center
Ann G Egland is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Association of Military Surgeons of the US, Medical Society of Virginia, and Society for Academic Emergency Medicine
Editors: Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School; Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
ingrown nails, ingrown fingernail, ingrown toenail, acronyx, onychocryptosis, unguis incarnatus, unguis aduncus
Background
Ingrown toenails are a fairly frequent cause of discomfort. Although often thought to be synonymous, the terms ingrown nail and paronychia refer to different conditions. Both can cause significant discomfort. Ingrown toenails may cause pain with ambulation.
Pathophysiology
Ingrown nails result from an alteration in the proper fit of the nail plate in the usual nail groove. Sharp spicules of the lateral nail margin develop and are gradually driven into the dermis of the nail groove. The nail acts as a foreign body. An inflammatory response occurs in the area of penetration, leading to erythema, edema, purulence, and development of granulation tissue.
Development of ingrown nails is divided into 3 stages: (1) erythema, edema, and focal tenderness; (2) crusting and expressible purulence at the nail fold and nail plate junction; and (3) chronic infection with protuberant granulation tissue extending over the nail plate.
Ingrown nails generally occur as the result of poorly fitted footgear. However, this may be caused by prior trauma to or abnormal shape of the nail margin.
Frequency
United States
Of all nail problems, this is the most common. Toenails are affected much more commonly than fingernails. The lateral margins of the great toe are most frequently affected.
International
In the United Kingdom, 10,000 cases per year have been reported.
Mortality/Morbidity
In general, mortality is not associated with ingrown nails. Morbidity is chiefly the result of infection of the tissues. If neglected, abscess formation (paronychia) may occur or spread and lead to osteomyelitis, systemic infection, sepsis, or amputation.
Race
No racial bias appears to exist.
Sex
The prevalence of ingrown nail has a reported male-to-female ratio of 3:1.
Age
The condition is observed in people of all ages but is most common in the second decade of life.
Ingrown nails become much more common as children begin bearing weight on their feet and wearing shoes.
History
Patients present for care of ingrown nails due to discomfort. Ingrown nails may cause significant pain.
If a toenail is involved, the discomfort worsens with weightbearing and ambulation.
- The patient with an ingrown nail presents with a sharp, focal pain adjacent to the nail bed of the affected digit.
- The patient or parents may typically describe crusting, purulence, and friable granulation tissue at the site.
Physical
On examination, the following may be present:
- Edema or inflammation of tissue surrounding the nail bed
- Erythema of the same tissue
- Macerated or friable granulation tissue
- Crusting
- Drainage
- Hypertrophy of the nail margin
- Hypertrophy of the surrounding epidermis
Causes
The nail plate can be forced out of the nail groove by footgear that has a toe box that is too small for the forefoot, by trauma, or by cutting the nail back in a curvilinear fashion.
- Other causes include the following:
- Heredity - Some people are genetically predisposed to inwardly curved nails with distortion of one or both nail margins.
- Underlying bony pathology causing deformation of the nail
- Obesity causing deepening of the nail groove
- Antiviral therapy for HIV has also been reported to have an association with increased incidence of ingrown nails.
- Prior trauma resulting in an irregularly shaped nail
Impetigo
Lymphangitis
Obesity
Osteomyelitis
Staphylococcus Aureus Infection
Streptococcal Infection, Group A
Other Problems to be Considered
Paronychia
Fracture
Osteomyelitis
Foreign body
Bunion
Pyogenic granuloma
Mucous cysts
Subungual exostoses
Junctional nevi
Periungual fibroma
Candidiasis
Herpetic whitlow
Cellulitis
Lab Studies
- Usually, no laboratory studies are required. Potassium chloride (KOH) and fungal culture may be considered, if indicated by physical examination findings suspicious for a fungal etiology.
Imaging Studies
- Radiography may be appropriate to rule out fracture, foreign body, or suspected osteomyelitis as indicated by history and physical examination.
Medical Care
Treatment options depend on the stage of onychocryptosis.
Development of ingrown nails is divided into 3 stages: Stage 1, erythema, edema, and focal tenderness; stage 2, crusting and expressible purulence at the nail fold and nail plate junction; and stage 3, chronic infection with protuberant granulation tissue extending over the nail plate.
- Stage 1 can be managed by recommending shoes with a comfortable wide toe box or open-toed shoes. Instruct the patient's parents to cut the nail straight across and avoid cutting back the lateral margins. The nail edge should extend past the tissue.
- Stage 2 can be treated by stretching the soft tissue away from the side of the nail, elevating the offending edge of nail from the soft tissue, and placing a small pledget of cotton under the nail edge to lift it back into the nail grove. Instruct patients with stage 2 ingrown nails on how to perform this treatment. Parents should also be instructed to have the child rest, keep the foot elevated, and use warm soaks.
- Stage 3 should be treated by removing the nail margin in a minor surgical outpatient procedure as described in Surgical Care below. Chronic ingrown toenails may require matrix ablation. This may be accomplished by surgical excision of a portion of the nail with ablation of the underlying matrix.
- Ablation is usually carried out by electrocautery of the underlying matrix. Caution must be used to avoid affecting tissue deep to the matrix.
- The Cochrane Collaboration reports enhanced result for treatment of chronic ingrown nails by the addition of a chemical ablatant, phenol. Phenol is applied via a cotton-tipped applicator to the nail matrix to destroy the lateral portion of the matrix.
Surgical Care
Stage 3 ingrown nails require avulsion of the lateral border of the nail plate with sharp excision of the hypertrophic granulation tissue. If avulsion has been unsuccessful in the past, partial or total ablation of the nail plate chemically, surgically, or via laser may be indicated.
Ablation is usually carried out by electrocautery of the underlying matrix. Caution must be used to avoid affecting tissue deep to the matrix.
- Prepare the digit with Betadine or alcohol if the patient is iodine allergic. Perform a digital block with 2% lidocaine without epinephrine.
- Lift the nail off of the nail matrix bluntly all the way back to approximately one eighth of an inch under the proximal nail fold.
- Insert a nail anvil and cut the nail back to the proximal nail fold.
- Remove the free portion of the nail.
- Protuberant granulation tissue can be removed sharply or treated with silver nitrate.
- Bleeding, if any, is controlled with pressure.
- Antibiotic ointment and clean dressing should be applied.
Consultations
- Consult a podiatrist, dermatologist, or orthopedic surgeon for routine follow-up care or for patients in whom primary avulsion therapy has been unsuccessful.
- Close follow-up care with an orthopedist is required if inflammatory osteophytic changes are observed or if evidence of osteomyelitis is present. Immediate antibiotic treatment should begin, and inpatient treatment may be needed for osteomyelitis.
- Follow-up with a primary care physician is indicated for any type of immunosuppression, including diabetes mellitus. Antibiotics may be started in those who are immunosuppressed.
Diet
No dietary limitations are required.
Activity
Rest, keep the extremity elevated, keep the site dry, and maintain limited weightbearing until healing has taken place.
Antibiotics are rarely indicated for ingrown nails. Patients may generally be treated as outpatients. Pain control should be provided.
Drug Category: Analgesic agents
Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.
| Drug Name | Ibuprofen (Motrin, Ibuprin) |
|---|
| Description | Nonsteroidal anti-inflammatory pain control and treatment of local inflammation. |
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| Adult Dose | 200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d |
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| Pediatric Dose | 8-10 mg/kg PO q6h prn for pain |
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| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding |
|---|
| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy |
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| Drug Name | Acetaminophen (Feverall, Tylenol) |
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| Description | DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking PO anticoagulants. |
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| Adult Dose | 325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d |
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| Pediatric Dose | 10-15 mg/kg PO q4h prn for pain; not to exceed 2.6 g/d |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Hepatotoxicity possible in people with long-term alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative doses exceeding recommended maximum |
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Further Inpatient Care
- This condition is usually treated on an outpatient basis.
Further Outpatient Care
- Provide appropriate follow-up care as indicated.
- Provide patients and parents with specific indications for return, such as development of infection, bleeding, or any worsening of the condition of the digit.
Deterrence/Prevention
- Good hygiene and wearing appropriately sized footgear are important. Shoes with narrow, pointed toes that compress the forefoot should not be worn.
- Teaching the patient and parents to keep the nail margin in the nail groove, how to properly trim the nail, and how to choose shoes with an accommodating toe box is vital to prevent further visits.
Complications
- Development of paronychia is the most common complication. If paronychia is not treated, the condition may progress to cellulitis, osteomyelitis, or systemic infection.
- If neglected, abscess formation (paronychia) can spread and lead to osteomyelitis, systemic infection, and sepsis; amputation of the digit may even be required for definitive treatment.
- Although infrequent, postsurgical infection may occur in a small percentage of patients. Appropriate precautions should be given to return for any signs of infection or fever.
Prognosis
- Prognosis is excellent. Complete healing is expected.
Patient Education
Medical/Legal Pitfalls
- Pitfalls include misdiagnosis of ingrown nail when more widespread infection is present and failure to recognize associated trauma, such as fracture of the affected digit.
The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Thomas Craig, MD to the development and writing of this article.
| Media file 1:
Ingrown nails. Right great toe paronychia in a 3-year-old child. Photo courtesy of Ann G. Egland, MD. |
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| Media file 2:
Ingrown nails. Preparing for digital block before surgical treatment of paronychia of right great toe. Universal precautions should always be observed. Photo courtesy of Ann G. Egland, MD. |
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Ingrown Nails excerpt Article Last Updated: Jul 19, 2006
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