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

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

26 April 2012
Just AH Eekhof
General Practitioner
Bart van Wijk, Arie Knuistingh Neven and Johannes C van der Wouden
Department of Public Health and Primary Care, Leiden University Medical Center
PO Box 9600, 2300 RC Leiden, the Netherlands