The management of ingrowing toenails
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2089 (Published 03 April 2012) Cite this as: BMJ 2012;344:e2089
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With interest we read the review by Park and Singh in which the authors give a concise overview on the management of ingrown toenails with a special focus on the different surgical treatments. [1] However, in recent literature orthonyxia (nail brace) has been advocated as an alternative treatment for ingrown toenails. [2-5]
A search in the Medline-database on studies that compare orthonyxia with other treatment options in patients with ingrown toenails yielded 6 hits, of which 4 articles were fully read (search strategy: ("Nails, Ingrown"[Majr]) AND ("Braces"[Mesh] OR orthon*)). [2-5] Of these studies, 2 compared orthonyxia with surgical treatment [2,3], one study compared with conservative treatment. [4] One study evaluated the longitudinal use of orthonyxia in patients with diabetes, and the study by Matsumoto et al. described a new technique of orthonyxia. [5,6] Because of the lack of a control group, the last 2 studies were not used for further evaluation.
In a randomized controlled study, rated to be of high methodological quality using the Cochrane criteria, Kruijff et al. compared orthonyxia with partial matrix excision. They evaluated 105 patients with 109 cases of ingrown toenails and found no statistical difference in recurrence of ingrown toenails (p=0.14), while orthonyxia was the treatment of choice regarding morbidity, activity and patient satisfaction (p<0.01). [2] Harrer et al. also evaluated orthonyxia with surgical treatment; they included 41 patients to both groups on a consecutive basis. Since they did not use strict randomisation, we rated this study to be of lower quality.[3] No significant difference in recurrence rate between orthonyxia and surgical treatment (p=0.68) was found, while orthonyxia did lead to less pain (p<0.01) and a reduced need for pain killers (0% versus 35% respectively). Moreover, they found a reduction in cost of $1641 per treated patient when including employer costs into account for the treatment of ingrown toenails with orthonyxia. In a Danish study, 39 patients with bilateral unguis incarnatus were included and each toe was randomised to either conservative treatment or orthonyxia. [4] Based on patient preference, treatment of choice was orthonyxia (p<0.01).
This analyses of recent literature on the treatment of ingrown toenails with orthonyxia clearly shows that it is a safe and effective treatment. No significant differences in recurrence rate between orthonyxia and surgical treatment were found. Orthonyxia was superior compared to surgical treatment with respect to pain, time to recovery, patient satisfaction and cost. We suggest that orthonyxia should be considered as first-line therapy for ingrown toenails before surgical treatment is advised.
References
1. Park DH, Singh D. The management of ingrowing toenails. BMJ 2012;344:e2089.
2. Kruijff S, van Det RJ, van der Meer GT, van den Berg IC, van der Palen J, Geelkerken RH. Partial matrix excision of orthonyxia for ingrowing toenails. J Am Coll Surg 2008;206:148-53.
3. Harrer J, Schöffl V, Hohenberger W, Schneider I. Treatment of ingrown toenails using a new conservative method: a prospective study comparing brace treatment with Emmert’s procedure. J Am Podiatr Med Assoc 2005;95:542-9.
4. Beck J, Nielsen J. Orthonyxia compared with the conservative treatment in ingrown nails of the great toe. A controlled study. Ugeskr Laeger 1984;146:3537-8.
5. Erdogan FG, Erdogan G. Long-term results of nail brace application in diabetic patients with ingrown nails. Dermatol Surg 2008;34:84-6.
6. Matsumoto K, Hashimoto I, Nakanishi H, Kubo Y, Murao K, Arase S. Resin splint as a new conservative treatment for ingrown toenails. J Med Invest 2010;47:321-5.
Competing interests: No competing interests
The management of ingrowing toenails
BMJ 2012; 344 doi: 10.1136/bmj.e2089 (Published 3 April 2012)
Cite this as: BMJ 2012;344:e2089
Had there been more space in this Clinical Review by Derek Park and Dishan Singh, I am sure they would have mentioned that ingrowing toenails may be a presenting feature of diabetes or peripheral vascular disease. Operating on such patients could lead to unfortunate complications. Also, a comment that a subungual melanoma or subungual exostosis may mimic an ingrowing toenail could prevent serious errors.
All this information and more is available on Wikisurgery.com, the free on line surgical encyclopedia.
Competing interests: No competing interests
Responding to the article 'The Management of Ingrowing Toenails'
(BMJ 2010;344:e2089), I have found one useful addition to the conservative management of early disease is to ask the patient to use a toothbrush and brush gently up and down in the nail side gutter. At first the toe is very tender so only a gentle touch is possible but, as the inflammation settles, the brushing can be increased. This is also effective after an excision of a wedge of nail only (useful because it does not damage the nail bed and is less painful post-operatively), as the inflammation heals.
I also add that I have never seen a so-called 'nail spike'. It seems more sensible to consider this condition begins as a simple paronychia (bacterial or fungal) causing oedema of the tissue lateral to the nail which then 'grows over' the nail rather than the nail 'growing in'. A viscious circle is set up with increasing pressure and obstruction on the nail gutter. Hence the effectiveness of the brushing treatment I describe.
Competing interests: No competing interests
Parks and Dishan provide a comprehensive review of the management of this age-old problem but do not perhaps enlighten us fully on why a natural structure (the nail) should misbehave in such a troublesome way in so many members of the human race. Does the condition, for example, occur in the non shoe-wearing world. And can the 'spike of nail' theory, or inappropriate trimming, really explain the pathology?
It's common knowledge to hand surgeons that the morphology of the human nail is heavily dependent upon the support of the underlying phalanx, with which it is normally in intimate contact. When that support fails, then the nail shape collapses, as for example seen when the distal edge of the nail 'beaks' around the tip of the finger after tiny tip amputations. Most hand surgeons receive, because of the parallels between hand and foot, a small but steady request for opinions on in-growing toe-nails. Over the years, its been my observation that in almost all cases of ingrowing toe nail there is an abnormally narrow distal phalanx in relation to the width of the germinal matrix area. Thus a wide nail grows out, receives no support from the bone and therefore simply 'drops over the edge' of the phalanx, and with added pressure from the shoe, eventually ulcerating the deepened nail fold. Neither nail spikes nor improper cutting are really the primary issue, I submit.
Competing interests: No competing interests
Toenail fungus (onychomycosis) and its accompanying inflammation (paronychia) are common, chronic, painful conditions. In my experience, both respond well to tea tree oil (melaleuca oil), which is applied topically and locally once or twice a day, and which may obviate the need for surgery and/or potentially toxic medications. I also advise that patients refrain from trimming cuticles, because this can break the waterproof seal around the nail bed, and create an environment for fungus. (1)
Competing interests: No competing interests
Re: The management of ingrowing toenails
We welcome this clinical review, paying attention to a very common condition.1 The authors make recommendations about both non-surgical and surgical interventions for an ingrown toenail. For surgical interventions, recommendations are based on the Cochrane review that was published in 2005.2
Very recently the updated Cochrane review was released, which now covers both non-surgical and surgical interventions for ingrowing toenails.3 We found 24 randomised trials fulfilling our inclusion criteria, only 7 of which were included in the previous Cochrane review. We did not find any randomised trials to support the advice for the non-surgical interventions the authors recommend. Interestingly, in none of the studies included in the review was the three stage division the authors recommend used.
Regarding surgical interventions, the evidence is different from what the authors state. The more intensive surgical interventions are more effective than partial nail avulsion (both without the addition of phenol). The conclusion in the previous review that the addition of phenol to a surgical intervention is effective was in our view unjustified. The surgical interventions in both arms of these studies were not equal, so it is not clear if the reduction in recurrence rate was caused by the addition of phenol. Only one study provides some evidence that addition of phenol is effective.4 The recurrence rate cited by the authors for surgical intervention with phenol (<5%) differs from the recurrence rate Bos reported (14%).
More studies are needed to confirm the effectiveness of the addition of phenol to a surgical procedure, and also new trials are needed to determine the place of non-surgical interventions in the treatment of stage I and II ingrowing toenails.
1. Park DH, Singh S. The management of ingrowing toenails. BMJ 2012;344:e2089.
2. Rounding C, Bloomsfield S. Surgical treatments for ingrowing toenails. Cochrane Database Syst Rev 2005;2:CD001541.
3. Eekhof JAH, Van Wijk B, Knuistingh Neven A, van der Wouden JC. Interventions for ingrowing toenails. Cochrane Database Syst Rev 2012;4:CD001541.
4. Bos AM, van Tilburg MW, van Sorge AA, Klinkenbijl JH. Randomized clinical trial of surgical technique and local antibiotics for ingrowing toenail. Br J Surg 2007;94(3):292-6.
Competing interests: We are the authors of the revision of the Cochrane review Interventions for Ingrowing Toenails which was published this week