An ingrown toenail is a curved shaped nail which grows into the skin at the edges. Mild curvature of the nail may not result in much pain, but severe curvature can cause redness, swelling, considerable pain and infection. The medical term for an ingrown nail is onychocryptosis. “Onych/o” means nail, “crypt” means hidden and “osis” means disease or condition. The roots of the word describe a hidden nail condition, which is what happens in severe ingrown nail infections. The nail curves in and grows into the skin edges.
The skin becomes inflamed and as the swollen skin covers the nail, the nail edges become hidden. The nail corners can break through the skin, causing an opening in the skin and potential for infection. The medical term for an infected ingrown nail is paronychia. “Par/a” has many meanings, but is defined as alongside of, beside or near, “onych/o” means nail and “emia” means presence of an infectious agent and is shortened to “ia” in paronychia.
The most common area for an ingrown toenail is at the great toenail. Ingrown toenails are common in children who play sports such as soccer or football, in adults who wear certain types of shoes or in individuals with fungal toenails. Many cases can be self-treated, but severe cases may require a procedure and/or antibiotics. Ingrown toenails can be a very serious problem for diabetics or individuals with poor circulation and at the first sign they should seek treatment immediately.
Causes: Some individuals have a genetic predisposition to developing ingrown toenails and the problem can start early in life. More common causes of ingrown toenails include inappropriate shoefit, trauma and improper nail cutting technique. Shoes which are too small can place pressure on the toes and cause the nail edges to curve in. This is more common with rigid, narrow shoes, such as dress shoes or soccer cleats. Shoes which are too large can also cause ingrown toenails.
This is more common with running shoes or hiking boots, when the individual is going up and down hills. The foot slides back and forth in the shoe and the repetitive trauma at the toes increases the pressure on the nail, increasing the chance for an ingrown toenail. Socks which are too tight can also cause ingrown toenails and this tends to be more common with thin dress socks and stockings. This has also been reported to occur with the use of the Strassburg Sock, a soft night splint worn while sleeping and used to treat plantar fasciitis.
Blunt injury or trauma can cause ingrown toenails. Catching the toe on a table leg or bed post can initially cause injury to the toenail. Dropping something on the toe, even of moderate weight, can cause inflammation to the skin surrounding the nail and as the nail grows, it grows into the inflamed skin, worsening the condition. Sports, such as soccer, increase the chance of ingrown toenails. This is more common at a younger age when children are learning the sport and more likely to kick the ball with their toe.
Nails should be cut straight across and cutting the nails too short, cutting down the sides of the nails or excessively rounding the edges can all cause ingrown toenails. Individuals with hyperhidrosis, excessive foot sweating, are at increased risk for ingrown toenails because the excess moisture weakens the skin and increases the chance for bacterial infection. Individuals with a fungal infection of the toenail (toenail fungus/onychomycosis) are at higher risk for developing ingrown nails. The fungus affects the nail bed and distorts the shape of the nail.
Signs and Symptoms: The early signs of an ingrown nail are tenderness along the nail edge, with or without swelling or redness. Many times individuals report dull, generalized pain at their toe when walking or in shoes. In some cases individuals only feel this pain at night, when the bed sheets and covers place pressure on the toe. This pain is reproduced when palpating the nail border. The skin edge may be hard or swollen. As the condition worsens, the skin edge becomes red, the area swells, becomes tender and very painful. There may be oozing, bleeding or pus and the drainage may show up on the socks. Moderate redness and swelling are signs of inflammation, but a significant amount of redness and swelling, pus or red streaks indicate infection.
Treatment: Treatment should be initiated at the first signs of an ingrown toenail to avoid worsening of the condition and possible infection. Soak the foot in warm water and epsom salts for 15-20 minutes three times a day. Wear open toed, or loose fitting shoes, avoid tight socks and decrease activity. The redness and tenderness should decrease within 2-3 days of foot soaking, but the soaking should be continued until all signs of inflammation have diminished. Don’t cut the nail on the edges or down the sides, this could further worsen the problem. If the redness worsens, if there is pus, excess drainage or streaking, see your healthcare provider immediately. If you are diabetic or have poor circulation, do not self-treat the condition.
If there are signs of infection, your doctor may prescribe antibiotics. In many cases, antibiotics can be avoided if the ingrown nail is addressed. A wedge resection of the nail can be performed. This involves your doctor using a specialized nail cutter to take out the wedge of nail growing into the skin. The procedure does not require anesthesia and works best when only the corner of the nail is growing into the skin. Soaks are recommended for 5-7 days following the wedge resection.
The second option is a nail avulsion. A nail avulsion is a partial or complete removal of the toenail. The toe is numbed with local anesthetic and the nail is freed from the surrounding skin and removed at the base. It is most common to remove only the section of nail which is causing the problem. The nail will always grow back in and depending on which toenail is removed, the nail can take up to 8 months to regrow. Warm water soaks with epsom salt twice a day for 5-7 days are recommended and typically a few days after the procedure, the toe is pain free. If the ingrown nail was due to trauma, poor shoe fit or poor cutting technique, when the nail regrows, it should grow in correctly and there should be no further problems or complications.
For individuals with recurrent ingrown toenails, a permanent nail procedure may be necessary. This procedure is called a matrixectomy and involves destroying or removing the root of the nail. A chemical matrixectomy is the most common procedure and this can be done in the office. The procedure is exactly the same as a nail avulsion, but a chemical (usually phenol or sodium hydroxide) is placed on the nail root to destroy it and prevent the nail, or side of the nail, from growing back. In some cases, surgical removal of the nail root may be necessary.
Prevention: The best treatment is prevention and this starts with proper care of your feet and toenails. Cut your nails straight across. Do not leave sharp edges at the corners, but do not excessively round the edges. Cut your nails regularly so they don’t become too long and hit the front of your shoes, but don’t cut your nails too short either. Make sure your shoes fit properly and avoid shoes which are too tight or too narrow. Avoid socks which are too tight and constricting. If you are diabetic or have poor circulation, see your podiatrist regularly.