Onychocryptosis – decrypting the controversies

Evaluation of the Recurrence Rate of Ingrown Toenail After a 45-Second Matrix Cauterization With Phenol

INTRODUCTION

Ingrown toenail is a very common nail disorder, and partial matricectomy by phenolization is considered the most effective treatment technique. However, the contact time of the phenol with the nail matrix remains debatable.

OBJECTIVE

To evaluate the recurrence rate of ingrown toenail after partial matricectomy by phenol for 45 seconds.

METHODS

A total of 1,460 surgeries were performed, with a photographic record of 802 pictures for a period of 6 months. The presence of any nail spicule or sign of ingrowth during follow-up was considered a recurrence.

RESULTS

A total of 802 surgeries were evaluated, with the most affected nails being the right (49.3%) and left (48%) big toes and most frequently the lateral fold (54.5%). The recurrence rate was 0.75% at 3 months and 1.87% at 6 months, and the medial nail fold had a higher recurrence rate than the lateral nail fold.

CONCLUSION

Forty-five seconds of contact time of 88% phenol with the nail matrix was enough and effective, resulting in low recurrence rates. Prospective studies are needed to better assess postoperative morbidity.

Surgical interventions for ingrown toenail

BACKGROUND

Paronychia is a prevalent clinical disease affecting the soft tissue surrounding the nails. Most cases of toenail paronychia are commonly associated with ingrown toenails. While conservative treatment is effective for mild cases of ingrown toenails, surgical intervention becomes necessary for moderate to severe cases, particularly when granulomas form.

OBJECTIVE

To provide a systematic understanding of these classic and modified procedures for surgeons to select the appropriate surgical interventions for patients suffering from moderate to severe ingrown toenails and discuss this technology's advantages and limitations for dermatologic surgery.

METHODS

A literature search was performed using PubMed/MEDLINE and Google Scholar databases. Studies discussing surgical intervention for ingrown toenails were included. Moreover, the surgical steps were meticulously depicted by detailed schematic diagrams.

RESULTS

These surgical techniques can be divided into three categories: matrix resection, debulking of periungual soft tissues, and the rotational flap technique. Each approach possesses distinct advantages and limitations.

CONCLUSION

For moderate to severe cases, surgical interventions may exhibit superior outcomes, faster recovery times, and lower recurrence rates. The surgeon must possess a comprehensive understanding and proficient skillset in various surgical techniques for ingrown toenails.

Imaging features for the evaluation of skin and nail infections

Clinical manifestations of dermatological and musculoskeletal conditions can sometimes overlap, leading to confusion in diagnosis. Patients with nail and skin infections may undergo imaging examinations with suspicions of muscle, tendon, or joint injuries. Dermatological infections often involve soft tissues and musculoskeletal structures, and their etiology can range from fungi, bacteria, viruses, to protozoa. Relying solely on physical examination may not be sufficient for accurate diagnosis and treatment planning, necessitating the use of complementary imaging exams. The objective of this paper is to present and discuss imaging findings of the main infectious conditions affecting the nail apparatus and skin. The paper also highlights the importance of imaging in clarifying diagnostic uncertainties and guiding appropriate treatment for dermatological conditions.

A systematic review and meta-analysis of randomised controlled trials of surgical treatments for ingrown toenails part II: healing time, post-operative complications, pain, and participant satisfaction

BACKGROUND

When performing nail surgery, clinicians must choose from a multitude of procedures and variations within each procedure. Much has been published to guide this decision making, but there are a lack of up to date robust systematic reviews to assess the totality of this evidence.

METHODS

Five databases (MEDLINE, Embase, CINAHL, Web of Science and CENTRAL) and two registers (Clinicaltrials.gov and ISRCTN) were searched to January 2022 for randomised trials evaluating the effects of a surgical intervention(s) for ingrown toenails. Two independent reviewers screened records, extracted data, assessed risk of bias and certainty of evidence. Data on co-primary outcomes of symptom relief and symptomatic regrowth were presented in our first paper. This paper presents data for the secondary outcomes and further discussion.

RESULTS

Of 3,928 records identified, 36 randomised trials were included in the systematic review. Healing time appears to be reduced with shorter application of phenol. A reduced healing time was also apparent was with the addition of curettage, although this may also increase the risk of post-operative bleeding and pain. Post operative bleeding was also reportedly lower in people who received local anaesthetic with epinephrine but no tourniquet. Use of phenol with nail bed excision may decrease the risk of infection. Lower pain scores were reported when using partial matrixectomy and surgical interventions with phenol. Shorter duration of pain was reported with phenolisation and wedge resection. Participant satisfaction was high overall.

CONCLUSION

This second paper reports secondary outcomes from a robust systematic review of randomised trials on surgical treatment of ingrown toenails. Despite the large volume of clinical trials conducted on the topic, few clinical conclusions can be drawn due to the poor quality of these studies. Further high-quality clinical trials are needed to answer fundamental questions in the surgical treatment of ingrown toenails.

Comparative study between nail retraining with gauze bandaging and the nail remodeling with acrylics as a conservative treatment for stage I and IIa onychocryptosis

OBJECTIVE

Onychocryptosis is one of the most prevalent onychopathies, being a frequent reason for consultation in podiatric clinical practice. Conservative treatments are the first therapeutic choice, with nail remodeling using clotrimazole gel emerging as an alternative, although its medium-term effectiveness is unknown. The objective of this study was therefore to compare the efficacy of the technique of nail retraining using gauze bandaging with that of nail remodeling for the conservative treatment of stage I and IIA onychocryptosis.

METHODS

An analytical, randomized clinical trial study was performed following a longitudinal and prospective design. A sample was selected of 20 subjects presenting stage I and IIA onychocryptosis. Of these, 10 cases formed the group of nail retraining using gauze bandaging, and the other 10 the nail remodeling group. The presence of recurrence in a 3-month period was evaluated.

RESULTS

Before the intervention, the patients in the retraining group presented pain of 6.7 ± 1.9 vs. 6.8 ± 1.6 in the remodeling group, with no significant difference between the two (p = 0.900). After the 3-month follow-up period, seven of the retraining group patients presented recurrence of onychocryptosis vs. only one in the remodeling group.

CONCLUSION

The technique of nail remodeling has a lower recurrence rate than that of nail retraining with gauze bandaging, with the pain, inflammation, and infection reported being less, and with greater patient satisfaction.

The association between foot alignment and the development of ingrown toenails: A case-control study in a young adult military population

BACKGROUND

This case-control study aimed to explore an association between foot alignment and development and presentation of the ingrown toenail.

METHODS

Radiographs were evaluated for hallux interphalangeal angle (HIA), hallux valgus angle (HVA), talonavicular coverage angle (TNC), talo-first metatarsal (Meary's) angle, and calcaneal pitch angle (CP), as well as medial sesamoid position in a cohort of 103 young and healthy patients (mean age of 20.5 years) with ingrown toenails. A control group of 63 patients was included, and the radiographic parameters were compared. Subgroup analysis was performed in patients with lateral (n = 65) or medial (n = 38) nail fold involvement.

RESULTS

The overall study group demonstrated a larger TNC and Meary's angle and smaller CP than the control group, while no significant difference was found regarding the HIA and HVA. The lateral nail fold group had a larger HIA when compared to the medial nail fold group. Multiple regression analysis revealed that for ingrown toenail development, the only risk factor was a decrease in the CP. In the case of lateral nail fold involvement, an increase in the HIA found to be the only factor.

CONCLUSION

A lower medial longitudinal arch seems to be a predisposing factor in developing an ingrown toenail. The lateral nail fold involvement was associated with lateral deviation of the distal phalanx. The result of this study could provide information on prevention, treatment, recurrence, and patient counseling of an ingrown toenail in otherwise young and healthy individuals.

Efficacy and safety of phenol based partial matricectomy in treatment of onychocryptosis: A systematic review and meta-analysis

Chemical matricectomy is an established treatment modality of onychocryptosis. In this meta-analysis we studied the efficacy and safety profile of phenol-based matricectomy. We performed an electronic data base search of PubMed, EMBASE and gray literature using the search terms "(onychocryptosis OR ingrown toe nail) AND (phenol OR chemical matricectomy)" from inception till 31-12-2020, for controlled clinical trials with phenol in one of the treatment arms and at least 10 participants in each arm. From the initial search of 335, eighteen articles were included in the final analysis. There were a total of 1655 patients, of which 856 received phenol as an intervention modality. We found that nail matrix phenolisation was associated with a 49 fewer number of recurrences per thousand patients compared to other modalities (OR: 0.28 - 0.57, CI 95%). It also had a reduction of 175 cases of discharge or hemorrhage per thousand patients compared to other modalities (OR:0.25, 95% CI:0.14 to 0.45). However, we found that TCA and NaOH based matricectomies fared better compared to phenol in incidence of postoperative discharge and hemorrhage. Patients also experienced less pain (257 fewer number per 1000, OR: 0.52, 95% CI:0.43 to 0.63). Nearly half of the included studies had some concerns about the risk of bias. As of now, phenol matricectomy combines a low recurrence rate with favourable adverse effect profile and is the preferred modality for matricectomy in grade II and III onychocryptosis.

Electrodessication Matricectomy With Modified Hyfrecator Tip: Case Series and Literature Review

Nail matricectomy is indicated in the management of painful onychodystrophies, including recalcitrant onychocryptosis, onychogryphosis, onychauxis, and refractory onychomycosis. Although many matricectomy methods have been described, with phenolization being the best studied, no one method has clearly emerged as superior. We present a series of 14 patients who underwent a total of 18 matricectomies with either phenolization or electrodessication (ED) in a private dermatology office, and describe a simple and effective variation of the ED technique using a modified hyfrecator tip. A video demonstration of this technique is included. We also describe ED matricectomy in the context of a review of the literature, ascertaining recurrence rates, complication rates, healing time, and patient satisfaction. The nuances of technique specifics (such as the use of adjunct methods and antibiotics), as well as outcome predictors and measurements have been highlighted. We found ED to be comparable to other forms of matricectomy, with the advantages of ease of use, minimal complications, and good satisfaction rates.

Conservative management of a severe case of onychocryptosis at a podiatric clinic-A case report

BACKGROUND

Onychocryptosis, also known as ingrown toenails or ungues incarnati, is a fairly frequent condition, with global prevalence of approximately 20%.

OBJECTIVES

This study is aimed at discussing possible conservative management of severe onychocryptosis, with a case report.

METHODS

Conservative approach is effective in reducing or even entirely correcting underlying nail deformities. Eliminating nail fold inflammation is necessary prior to the bracing procedure. The non-surgical approach combined with proper wound treatment of the involved nail folds is a promising alternative for a growing number of patients.

RESULTS

Nail plate deformities may be largely corrected or fully eliminated. As demonstrated by our case report, even advanced stages of onychocryptosis may be effectively treated with nonsurgical modalities.

CONCLUSION

Proper podiatric care facilitates conservative approach to management of ingrown toenails, improving the patient's overall wellbeing and eliminating pain. The prerequisite for nonsurgical correction of the nail plate is treating inflammation first. Conservative correction is more aesthetically pleasing and less emotionally disturbing to the patients than partial or complete surgical avulsion. Lesser invasiveness is an advantage especially in the case of patients with chronic comorbidities.