Intended for healthcare professionals

Clinical Review

The management of ingrowing toenails

BMJ 2012; 344 doi: (Published 03 April 2012) Cite this as: BMJ 2012;344:e2089

Re: The management of ingrowing toenails

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

13 April 2012
Peter J Mahaffey
Plastic & Hand Surgeon
Bedford Hospital
Kempston Rd Bedford MK42 9DJ