There are a myriad methods to treat ingrowing toenails. Some very helpful ones are presented here.
Treatment of ingrowing toenails is a potential legal ‘minefield’, especially with wedge resection.
Keep in mind the following:
Full and detailed discussion with the patient about the procedure used and its risks is recommended.
Avoid adrenaline with the local anaesthetic—use plain lidocaine or bupivacaine.
Avoid prolonged use of a tourniquet and do not forget to remove a rubber band if used.
Avoid tight circumferential dressings.
Be careful with diabetics and those with peripheral vascular diseases.
Avoid excessive use of phenol for nail bed cautery.
Give clear post-operative instructions.
It is best to treat when the infection settles.
It is important to fashion the toenails so that the corners project beyond the skin (Fig. 8.8). Then each day, after a shower or bath, use the pads of both thumbs to pull the nail folds as indicated.1
Stretch nail folds with thumb daily
This simple technique involves the application of strong adhesive tape such as Elastoplast® or Leukosilk® 12.5 mm to retract the skin off the ingrowing nail. At first use the thumb pads, despite the discomfort, to retract the skin. The tape is then passed around the plantar surface to anchor the tape in loops around the proximal aspect of the toe (Fig. 8.9). The application of Friar’s Balsam to the distal ‘achor’ gives a better grip. This process is repeated 2 to 4 times weekly until the problem settles.2
The spiral tape method for the ingrowing toenail
An interesting method for the prevention and treatment of ingrowing toenails is to thin out a central strip of the nail plate. This is usually performed with the blade of a stitch remover or a no. 15 scalpel blade.
The central strip is about 5 mm wide and is thinned out on a regular basis (Fig. 8.10).
Illustrating strip of nail plate to thin out
Excision of ellipse of skin
Figure 8.11 shows the toe in extremis. The procedure transposes the skinfold away from the nail. The skin heals, the nail grows normally and the toe retains its normal anatomy.
An elliptical excision is made after a digital block (Fig. 8.12a). The width of the excision depends on the amount of movement of the skinfold required to fully expose the nail edge.
The skinfold is forced off the nail (Fig. 8.12b). Any blunt instrument can be used for this purpose. The wound closure holds the fold in its new position.
Any granulation tissue and debris should be removed with a curette. The toe heals well, and there are usually no recurrences of ingrowing.
Excision of ellipse of skin
If the nail is severely ingrown, causing granulation tissue or infection of the skin or both, a most effective method is to use electrocautery to remove a large wedge of skin and granulation tissue so that the ingrown nail stands free of skin (Fig. 8.13).
Electrocautery to wedge of tissue
This is performed under digital block. The toe heals surprisingly quickly and well (with minimal pain). The long-term result is excellent, because the nail that is not cut in this procedure can grow (and be trimmed) free of flesh.