Symptoms
Ingrown toenails may lead to pain and redness, and most commonly involve the big toe. An ingrown toenail may become locally infected with a pus discharge and require several courses of antibiotics before settling. It is not uncommon for an ingrown toenail to recur.
Why do ingrowing toenails occur?
Certain toenail shapes, particularly those that are excessively curved into the soft-tissues, or inappropriate cutting of the nail will predispose to the condition. The painful area is usually on one side of the toenail, although it is not uncommon for both sides to be involved. In addition, occasionally multiple toes can be afflicted with ingrown toenails.
Treatment
Ingrown toenails are treated by reducing the soft tissue swelling, addressing any local infection, controlling the pain, and appropriate trimming of the nails in order to minimise the chance of a recurrence.
Reducing the swelling
Soaking the toe in warm salt (saline) water can help kill the local bacteria and soften up the inflammed soft tissue. Ten minute soaks, performed 2-3 times per day, may result in less tissue swelling and therefore an improvement in symptoms.
Addressing any local infection
In most instances, the local infection will clear up when the inflamed soft-tissue has settled. Warm salt-water soaks can be helpful. On rare occasions, antibiotics may need to be prescribed to control the infection.
Controlling the Pain
Comfort shoes with a wide toe box are important in the treatment of an acute ingrown toenail. Repetitive bumping up against a tight shoe will be painful and may worsen the condition. Acetaminophen or non-steroidal anti-inflammatory medication may also be used to help control the symptoms of pain in the short term.
Appropriate Trimming of the Toenail
Cutting the toenail straight across is a key component of successfully treating ingrown toenails. Excessively cutting the edges of the toenail may provide some initial relief but may worsen the problem as the toenail grows back.
Surgery
Fortunately, most ingrown toenails can be treated without surgery. However, for abnormally shaped toenails and others sources of painful recurrent ingrown toenails that cannot be controlled with normal non-operative treatment, surgery may be indicated.
Before surgery
Your fitness for surgery and your foot and ankle symptoms will be reassessed in our pre assessment clinic, which usually takes place prior to the date of operation. Blood tests and further investigations of the heart and lungs may be required to ensure you are fit to have a general anaesthetic. If you live alone, we will liaise with your GP and social services to ensure that care is in place to look after you following surgery. Occasionally, you may need to spend a few extra days in hospital whilst the services are being organised.
We kindly ask that you contact us if you suffer an insect bite, cut or bruise to the symptomatic foot in the period leading up to your surgery, or if you have been unwell. Any injury to the skin in the area of your intended surgery can increase the risk of infection. You may need reassessment and surgery reorganised for another time.
On the day of the surgery
You will be seen before surgery by Mr Davda or team member to check your consent and mark the leg. Toenail surgery is typically performed under general anaesthetic, which can be discussed with your anaesthetist.
You will be able to go home the same day. Sometimes, it is necessary to spend a night in hospital depending on your general health and immediate recovery from the operation. Local anaesthetic is also applied at the time of surgery to provide pain relief and numb the foot. This can last for up to a day after.
The Operation
Surgery may include:
- Removal of part of the toenail.
Removing the side of the nail that is growing into the inflammed soft tissue will clear the symptoms. However, as the nail grows back (~2mm/month), the ingrown toenail may recur.
- Removal of the toenail and removal (ablation) of the nail bed matrix.
Ablation of the nail matrix may be necessary for ingrown toenails that have an unusual shape, and are therefore at a high risk for recurrence, or if previous toenail removal has not successfully treated the condition. In this procedure, the toenail is removed and then the nail bed treated so that the nail will not grow back. This nail bed ablation can be done by surgically removing the nail or by treating it with a chemical such as Phenol that kills (cauterises) the cells in the nail bed from which the toenail grows. In some instances, not all of the cells will be killed or removed and recurrence of spikes of nail may recur.
- Removing the entire toenail.
For ingrown toenails involving the lesser toes (toes 2-5), or when there is tissue overgrowth on both sides of the toenail of the big toe, removal of the entire toenail maybe indicated. This will usually clear the symptoms, although recurrence of the ingrown toenail can occur as the toenail grows back.
After the operation
It is not uncommon for the wound to bleed a little and stain the bandaging, particularly when standing for the first time after the operation. You will be seen for follow up in the clinic 2 weeks after the operation.
For the first two weeks following surgery you are advised to elevate the foot on 2-3 pillows to help reduce any swelling in the ankle and promote healing of the wound. You are allowed to walk and weight bear, however I encourage you to do this for essential purposes only and rest the foot as much as possible. Painkillers taken on a regular basis are advised and should be started as soon as possible after surgery. Moving the ankle, foot and toes is important to avoid any stiffness developing following surgery.
Recovery
The toe will remain raw and sore for some months after surgery and will take up to six months to appear normal. Swelling is common and can take a year to recover.
Common Questions
When can I drive?
Patients having had their left foot operated on will usually be able to drive an automatic car within a week. Those who have had an operation on the right side will be able to drive after the banding has been removed at the post operative appointment. You are advised to contact your insurance company to ensure you are covered to drive.
When can I go back to work?
This will depend on the type of work you do. For example, if you have a desk job you may be able to return to work in 1-2 weeks provided you are able to rest and elevate your foot whilst sitting. If you do a physically demanding job, you will need 3 – 4 weeks off.
When can I return to sport?
You can usually return to sport 4- 6 weeks from the date of surgery. Recreational walking or light sporting activity can be resumed earlier.
Complications
Swelling - this is very common after surgery. It is a side effect, rather than a complication, and can take up to a year to recover. You may need a shoe size slightly larger than you normally wear during this period.
Infection - this can occur in a small percentage of patients. Minor infections normally settle after a short course of antibiotics.
Numbness and tingling - this occurs at the surgical site, as a result of minor nerve damage and usually recovers over the course of six months.
Recurrence – despite a thorough surgical clearance of the nail, the condition can reoccur and a second procedure may be required. This occurs very uncommonly.