The effect of phenol on ingrown toenail excision in children

Does Electrocauterization of the Matrix After the Wedge Resection of the Toe-Nail Affect Recurrence in Discrete Age Groups Differently? A Retrospective Analysis

The onychocryptosis, also known as ingrown toe-nails, is a painful, common disorder which is less common in children than in adults. The purpose of the present study was to focus on the effect of electrocautery matricectomy on recurrence rate and clinical outcomes in different age groups. We performed a retrospective assessment of 189 consecutive ingrown toe-nails surgeries. Electrocautery matricectomy was performed in 68 (49.2%) of 138 (73%) adults, 25 (49%) of 51 (27%) adolescents. Recurrence was observed in 11 (21.5%) adolescent patients, while recurrence was observed in 12 (8.6%) adult patients. Recurrence was observed in 9 (9.6%) of 93 patients in whom cautery was used, while 14 (14.5%) recurrences were observed in 96 patients who did not use cautery. When the adolescent patient group was evaluated separately, recurrence was observed in 2 (8%) of 25 patients in the cautery group, while recurrence was observed in 9 (34.6%) of 26 patients in the other group. EM addition to the wedge excision does not affect the results in adult patients, but it significantly reduces recurrence in adolescent patients. Especially in younger patients, it is recommended to complete the matricectomy with electrocoagulation.

Matrix Cauterization With Silver Nitrate in the Treatment of Ingrown Toenails in Children: Pilot Study

BACKGROUND

Although partial onychectomy with chemical matricectomy has been described asthe treatment of choice, there is sparse evidence in the literature regarding the use of silvernitrate for matricectomy. Our aim is to describe the effectiveness of silver nitrate for matrixcauterization after partial onychectomy.

METHODS

A prospective observational study was performed on patients with ingrown toenailsstage 2-3 who underwent partial onychectomy with silver nitrate chemical matricectomy during 2018-2019 in our institution. All patients were evaluated in the outpatient clinic on the 7th and 30th post-operative day and a telephone evaluation was performed every 6 months afterthe surgical procedure to date.

RESULTS

One hundred and twenty-three patients, who underwent 231 partial onychectomies with silver nitrate chemical matricectomy were included, with a median follow-up of 21 months (interquartile range, 12-29). The procedure had an effectiveness of 95.3%, with only 11 recur-rences (4.7%) reported so far on follow-up. Postoperative infections were observed in 4 patients (1.7%). Adverse effects, such as pain and postoperative drainage, were irrelevant in mostpatients.

CONCLUSIONS

Silver nitrate matricectomy after partial onychectomy is an effective and safealternative for the treatment of ingrown toenail in children, with scarce postoperative morbidityand low recurrence rate.

Matrix Cauterization With Silver Nitrate in the Treatment of Ingrown Toenails in Children: Pilot Study

BACKGROUND

Although partial onychectomy with chemical matricectomy has been described as the treatment of choice, there is sparse evidence in the literature regarding the use of silver nitrate for matricectomy. Our aim is to describe the effectiveness of silver nitrate for matrix cauterization after partial onychectomy.

METHODS

A prospective observational study was performed on patients with ingrown toenails stage 2-3 who underwent partial onychectomy with silver nitrate chemical matricectomy during 2018-2019 in our institution. All patients were evaluated in the outpatient clinic on the 7th and 30th post-operative day and a telephone evaluation was performed every 6 months after the surgical procedure to date.

RESULTS

One hundred and twenty-three patients, who underwent 231 partial onychectomies with silver nitrate chemical matricectomy were included, with a median follow-up of 21 months (interquartile range, 12-29). The procedure had an effectiveness of 95.3%, with only 11 recurrences (4.7%) reported so far on follow-up. Postoperative infections were observed in 4 patients (1.7%). Adverse effects, such as pain and postoperative drainage, were irrelevant in most patients.

CONCLUSIONS

Silver nitrate matricectomy after partial onychectomy is an effective and safe alternative for the treatment of ingrown toenail in children, with scarce postoperative morbidity and low recurrence rate.

The effectiveness of nail excision versus Vandenbos procedure for the surgical management of ingrown toenails in children: A retrospective chart review

BACKGROUND

Ingrown toenail commonly occurs in patients who have experienced trauma or long-term compression to their toes. There exist two common methods of surgical management - wedge resection and Vandenbos procedure. We compared the recurrence rate of these two methods in pediatric patients.

METHODS

We conducted a retrospective study reviewing patients who presented to our institution with ingrown toenail between 2009 and 2015. Patients who received any surgical treatment outside of our institution or were over 18 years of age were excluded.

RESULTS

There were 523 patients seen at our institution with ingrown toenail. Of these patients, 482 had sufficient data available to be included in this study, with a total of 929 ingrown toenails. Out of these, 333 were managed conservatively while the remaining 596 required surgical intervention; 373 had wedge resection performed and the other 223 had Vandenbos procedure. Our analysis determined that 78 total complications arose in the wedge resection group (21%) while 32 total complications arose in the Vandenbos group (14%; p = 0.0949). Wedge resections had a significantly higher recurrence rate than Vandenbos procedures (41 (11%) vs 5 (2%), p = 0.0001).

CONCLUSION

Surgical complications are comparable between wedge resections and Vandenbos procedure. Vandenbos procedure offers a significantly lower recurrence rate than wedge resection.

LEVEL OF EVIDENCE

Level III.

Patient Satisfaction with Treatment for Onychocryptosis: A Systematic Review

Onychocryptosis, or ingrown nail, is a common condition in which the nail plate penetrates the nail fold, often resulting in inflammation and pain. Nonsurgical and surgical treatments are utilized, but patient satisfaction with these therapies has not been well studied. The purpose of this study was to systematically review the available literature describing patient-reported outcomes of onychocryptosis treatments. We performed a search of the literature published prior to May 22, 2019. Articles were included in the review if primary data were presented, patient-reported outcome measures (PROMs) were used, and nail involvement was specifically examined. From the initial search, 18 studies were included in the final analysis. Patients receiving both nonsurgical and surgical interventions reported high levels of overall satisfaction; however, most studies used ad hoc measures rather than validated PROMs, providing little granular information on the impact of treatment on quality of life (QoL). This review affirms that treatment for onychocryptosis results in satisfactory outcomes for patients; however, increased efforts are needed to understand the impact of therapy on patient QoL as assessed by validated outcome measure that accurately assess patients' cosmetic, physical, and social difficulties.

Treatment of Ingrowing Toenails With Phenol 88% or Trichloroacetic Acid 100%: A Comparative, Prospective, Randomized, Double-Blind Study

BACKGROUND

Phenol is the gold standard for chemical matricectomy in ingrowing toenail. Recently, trichloroacetic acid (TCA) was used as cauterant. Both agents have high success rates but a postoperative healing time claimed to be faster for TCA rather than phenol.

OBJECTIVE

Comparing the efficacy, the postoperative oozing time, the inflammatory reaction, and the postoperative pain.

MATERIALS AND METHODS

Comparative, prospective, randomized, double-blind study. Eighty-four patients with 96 ingrowing toenails were randomized in 2 groups. Forty-six ingrowing toenails were treated with phenol 88% and 50 with TCA 100% within a 4-month period. Patients were observed 4 times for the presence of oozing and for the degree of inflammation. Patients assessed also oozing and pain on a scale basis during 34 days.

RESULTS

Oozing was observed to be less with phenol treatment, as from the second week. Inflammation was also significantly inferior in the phenol group at Week 4. Patients evaluated the incidence of pain below 2/10 for both cauterants, while oozing was higher with TCA during 34 days. The overall success rates of both groups were similar with 100%.

CONCLUSION

Phenol and TCA are both effective but TCA does not offer any advantage in terms of postoperative morbidity compared with phenol.

[Pediatric nail surgery]

BACKGROUND

Although interventions on the skin of children and adolescents often heal better than in adults, inappropriate interventions on nails can lead to avoidable trauma and irreparable damage to fingers and toes.

PROBLEMS

When are interventions on nails indicated in children? What age-related characteristics are important?

MATERIAL AND METHODS

With reference to the literature and experience from own clinical cases, the most commonly occurring constellations in children are discussed and approaches to protective treatment are demonstrated.

RESULTS

Ingrown toenails are one of the most common reasons for presentation due to nail problems in childhood. Conservative measures or protective interventions on the nail matrix avoid unnecessary trauma caused by currently obsolete techniques. Additional nail problems in children which could be treated operatively included nail pigmentation, exostosis and onychodystrophy.

CONCLUSION

A thorough evaluation of the indications and cautious implementation allows a targeted nail surgery or its avoidance even in childhood.

Teenage patients with ingrown toenails: treatment with partial matrix excision or segmental phenolization

Background:

Ingrown toenails (IT) is a very common problem leading to significant associated morbidity. The articles related to phenolization for matrix removal in teenagers with IT are not enough in the foot surgery literature.

Aims:

To compare the postoperative recovery periods, complication rate, and tolerability of partial matrix excision and segmental phenolization in teenagers with IT.

Materials and Methods:

Thirty-nine patients (13-17 years) with 48 IT were randomly divided into two groups and were treated with partial matrix excision (Group I) and segmental phenolization (Group II). We assessed the recurrence rates, postoperative complications, duration of analgesic usage, and time to return to daily activities.

Results:

There was no significant difference between the demographic and clinical data of the two groups. Three patients in Group I and two patients in Group II experienced moderate pain postoperatively. These patients used analgesics for 3 days. The rates of postoperative complications and recurrences between the two groups showed no statistically significant difference (P = 0.688). The time to return to normal daily activities was significantly shorter in Group II patients than in Group I patients (P < 0.05).

Conclusions:

Partial matrix excision is a very safe model of therapy in the surgical treatment of teenagers with IT. It has low recurrence rate and minimal postoperative morbidity. We concluded that segmental phenolization is also as safe as partial matrix excision in the treatment of IT and patients return to their daily activities in less time with this treatment modality.

Nail-fold excision for the treatment of ingrown toenail in children

OBJECTIVE

To evaluate the effectiveness of the nail-fold excision procedure in children.

STUDY DESIGN

Prospectively collected data on patients less than 18 years of age who underwent a nail-fold excision for symptomatic ingrown toenail were analyzed. Patients were seen in 2 centers and data collected included demographics, site of ingrown toenail, complications (including recurrence), patient satisfaction, and duration of follow-up.

RESULTS

Overall, 67 procedures were performed on 50 patients between June 2009 and July 2011 at the 2 institutions. The mean age was 14 years (range, 9-18 years) and 30 were male patients. No recurrences were seen after a follow-up for a median of 14 months (range 6-28 months). Patients were very satisfied with the cosmetic outcomes. Six minor complications occurred, including 3 patients with bleeding requiring dressing change, 2 with excessive granulation tissue, and 1 with nail growth abnormality.

CONCLUSIONS

The nail-fold excision technique is highly effective in the pediatric population, with no recurrence, excellent cosmesis, and very high patient satisfaction.

Controversies in the treatment of ingrown nails

Ingrown toenails are one of the most frequent nail disorders of young persons. They may negatively influence daily activities, cause discomfort and pain. Since more than 1000 years, many different treatments have been proposed. Today, conservative and surgical methods are available, which, when carried out with expertise, are able to cure the disease. Packing, taping, gutter treatment, and nail braces are options for relatively mild cases whereas surgery is exclusively done by physicians. Phenolisation of the lateral matrix horn is now the safest, simplest, and most commonly performed method with the lowest recurrence rate. Wedge excisions can no longer be recommended.

Results of partial matrixectomy for chronic ingrown toenail

BACKGROUND

Several treatment modalities which targeted partial matrixectomies, including chemical, laser matrixectomy, and partial nail avulsion, have been used in the dermatology, podiatry, and orthopaedic literature. We report our experience with surgical matrixectomy.

METHODS

We treated 224 patients with severe ingrowing toenails. Segmental wedge resection of involved margin was performed. Followup time was a minimum of 10 months.

RESULTS

Statistical analysis of recurrence and disease parameters such as stage of disease, infection, involved margin, previous surgery, followup time, and age showed no significant correlation (p>0.05). Twenty-two patients (9.8%) had a recurrence. Revision surgery was performed in 16 patients (7.1%).

CONCLUSION

We recommend the Winograd technique with a few modifications especially for severe Stage 2 and 3 cases. Both loupe magnification and observation of soft tissue in the postoperative period were important details.

Surgical treatment of ingrown toenails in children: what is best practice?

INTRODUCTION

Surgery for ingrowing toenails carries a significant re-operation rate. We reviewed our departmental figures to assess the optimal management of these patients.

PATIENTS AND METHODS

We performed a 10-year retrospective review of all patients undergoing surgery for ingrown toenails (IGTN) in order to determine the operations most commonly used and the re-operation rate of each of these procedures.

RESULTS

A total of 880 procedures were performed on 414 patients. The median age at operation was 8.5 years. About half (48%) of children underwent two or more procedures with wedge excision and phenol application being the most common initial and repeat procedure. Recurrent surgery was most likely following plain avulsion or wedge avulsion without phenol application. Excision of the nailbed with phenol application had the lowest recurrence rate at 18.4%.

CONCLUSIONS

We recommend wedge resection with phenol application as first-line treatment with simple avulsion reserved for severely infected toes. Total nail bed excisions should be reserved for patients with significant on-going morbidity associated with IGTN. Families must be made aware of the likely outcome of IGTN surgery and the choice of operation must be tailored to the individual.

Efficacy of intraoperative surgical irrigation with polihexanide and nitrofurazone in reducing bacterial load after nail removal surgery

BACKGROUND

A common challenge of nail avulsion surgery is the associated bacterial contamination and infection that can manifest. The toe has a difficult anatomy to antiseptically prepare and properly maintain throughout the surgical procedure, lending to this widespread problem.

OBJECTIVE

We conducted a controlled, prospective randomized study to examine the antiseptic efficacy of 3 intraoperative irrigation methods during nail avulsion surgery.

METHODS

We compared intraoperative antiseptic irrigation using 0.9% saline solution (24 patients), 0.2% nitrofurazone (22 patients), and 0.1% polihexanide (25 patients). Swab samples were taken from each patient at 5 distinct stages throughout the surgical procedure, and bacterial culture analysis was performed (positive culture rate, total inocula count, reduction of bacterial load, and identification of specific micro-organisms).

RESULTS

All 3 intraoperative irrigation methods reduced the total bacterial load, but polihexanide was significantly more effective. Furthermore, no patient from the polihexanide group developed postoperative infection. The reduction in bacterial load was lost for all 3 methods after partial nail avulsion surgery, returning to similar values as the initial presurgical bacterial load. An intraoperative irrigation step after partial nail avulsion with saline, nitrofurazone, and polihexanide was effective in reducing the bacterial load by 95.2%, 96.6%, and 99.5%, respectively.

LIMITATIONS

Our patients underwent phenol-based nail avulsion, resulting in no bacterial load after complete nail removal because of the intrinsic antiseptic nature of the phenol.

CONCLUSIONS

Intraoperative irrigation with 0.1% polihexanide substantially reduced the bacterial load and subsequent infections, highlighting the importance of an irrigation step in nail avulsion surgery.

Phenol chemical matricectomy is less painful, with shorter recovery times but higher recurrence rates, than surgical matricectomy: a patient's view

BACKGROUND

Ingrown toenails have a tendency for recurrence. Operative interventions can be successful, and several procedures are in use.

OBJECTIVE

Retrospective evaluation, to reveal differences in postoperative pain, time to recovery, and satisfaction with the cosmetic outcome in patients treated with a phenol (PCM) or surgical matricectomy (SM).

MATERIALS & METHODS

All matricectomy patients at the Dermatology Department of the Ludwigshafen City Hospital between 2004 and 2008 were interviewed over the telephone. Of 72 evaluable patients with a total of 112 ingrown nail sides, 33 were treated with PCM and 39 with SM. The patient group consisted of 40.3% women, the median age was 31.

RESULTS

Patients after PCM indicated two points less postoperative pain on an analogue scale from 0 to 10 (p<.001). In the PCM group, more patients recovered from the operation in less than 1 week (p=.007). Patient evaluation of cosmetic outcome was not different between the groups (p=.76), but recurrence rates were significantly higher in the PCM group (31.5%, vs 6.9% in the SM group, p=.006)

CONCLUSION

Both matricectomies have advantages and disadvantages. We should discuss these issues with our patients to help them decide on the kind of matricectomy.

Interpretation of radiologic abnormalities in patients with chronically infected ingrown toenails with regard to a possible exogenic osteomyelitis

BACKGROUND

Chronic infection of ingrown toenails may lead to exogenous osteomyelitis. Therefore, plain x-rays are commonly taken in children with significant inflammation. We evaluated the preoperative radiologic findings and their clinical significance, especially with regard to exogenic osteomyelitis.

PATIENTS AND METHODS

We retrospectively evaluated all patients who underwent surgery for infected ingrown toenails during a 5-year period. Data collection included the history of infection, preoperative laboratory tests, preoperative x-rays, and intraoperative presentation.

FINDINGS

One hundred thirty-four patients with infected ingrown nails of the hallux underwent 161 surgical procedures. Mean age at surgery was 14.1 years. Preoperative x-rays were taken in 113 (70.2%) cases. The treating surgeon classified 76 (67.2%) x-rays as negative (no bone affection), 16 (14.2%) as positive (definite bone affection), and 21 (18.6%) as suspicious for bone affection. Only 11 (30%) of 37 children with positive or suspicious x-rays showed bone affection during surgery, which presented as a softening of the cortical bone. None of the children had significantly elevated inflammation markers in the preoperative laboratory tests. Children with positive or suspicious x-rays had a significant longer history of infection compared to those without radiologic abnormalities (8 vs 4.5 weeks mean; P = .024). A reevaluation of the x-rays by an experienced radiologist was undertaken and revealed no case of definite osteolysis.

CONCLUSION

In about one third of all infected ingrown toenails, radiologic changes of the distal phalanx occur. These changes primarily represent periostal reactions. A typical osteomyelitis as a complication of chronically infected ingrown toenails is rare.

Treatment of ingrown toenails in the pediatric population

BACKGROUND/PURPOSE

Nail avulsion plus chemical matrixectomy (CM) using NaOH as an alternative to surgical matrixectomy (SM) has recently been used in the treatment of ingrown toenails (IGTNs) in adults. No studies exist to dictate the most effective and safe treatment method in the pediatric population.

METHODS

A retrospective review of pediatric IGTNs treated at 2 institutions for 6 years was done, looking at presentation, treatment modality, SM vs CM, and outcomes.

RESULTS

Eight hundred forty-eight IGTNs in 518 patients were reviewed with an average age of 12.5 years. Twenty-three percent were felt to be infected at the time of presentation, and 34% were being treated with antibiotics within the preceding week of surgery. Seventy-nine percent of toenails underwent surgical management with the most common procedure being avulsion plus SM (65%), followed by avulsion plus CM (17%), and avulsion alone (14%). The overall recurrence rate after initial surgery was 19.5%. After adjusting for covariates, recurrence was associated with treatment by avulsion alone (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.5-4.7), avulsion plus CM (OR, 0.3; 95% CI, 0.1-0.7), and treatment with antibiotics within the week before surgery (OR, 0.5; 95% CI, 0.3-0.9; P = .017). The overall postoperative infection rate was 6% and was unrelated to presence of preoperative infection, use of antibiotics, or surgical treatment method.

CONCLUSIONS

Ingrown toenails present a significant problem to youth and should be addressed in a diligent fashion. Chemical matrixectomy using NaOH is a safe and effective alternative to SM and maybe associated with a lower rate of recurrence, especially when use in conjunction with preoperative antibiotics.