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Baboun D, Yaghi M, Keri JE, Morrison BW. Natural Treatment Options for Nail Disorders. Skin Appendage Disord 2024; 10:83-91. [PMID: 38572187 PMCID: PMC10987172 DOI: 10.1159/000534629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/25/2023] [Indexed: 04/05/2024] Open
Abstract
The growing demand for natural treatments has raised concerns among clinicians due to limited scientific evidence supporting their use. This review article addresses the issue by assisting dermatologists and general practitioners in recommending natural treatments for the following common nail disorders: nail brittleness, onychomycosis, periungual verrucae, paronychia, chloronychia, nail psoriasis, nail lichen planus, onychocryptosis, onycholysis, and congenital malalignment of the great toenail. One limitation is the scarcity of existing reviews on natural treatment options for nail disorders in the literature. Through a comprehensive review of existing literature, this article consolidates the available evidence on natural treatment options for these conditions. Although some natural treatments for nail disorders are supported by scientific evidence, the indiscriminate use of such remedies may lead to severe poisoning and health problems. Given the widespread and increasing use of natural treatments, clinicians play a pivotal role in educating patients about evidence-based remedies and debunking misleading claims. By doing so, clinicians can enhance patient safety and improve treatment outcomes. It is essential for healthcare professionals to be well-informed and equipped with the knowledge to differentiate between effective natural treatments and unverified claims, ensuring that patients receive appropriate care.
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Affiliation(s)
- Daniela Baboun
- FIU Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Marita Yaghi
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Jonette E. Keri
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Brian W. Morrison
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
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de Almeida CÁ, Nakamura R, Leverone A, Costa F, Estrada BD, Haui P, Luz F, Yamada AF, Werner H, Canella C. Imaging features for the evaluation of skin and nail infections. Skeletal Radiol 2024:10.1007/s00256-023-04557-4. [PMID: 38194095 DOI: 10.1007/s00256-023-04557-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 01/10/2024]
Abstract
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.
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Affiliation(s)
- Carolina Ávila de Almeida
- Diagnósticos da América S/A, DASA, Avenida das Américas 4666, Sala 325, Rio de Janeiro, RJ, 22640-100, Brazil.
| | - Robertha Nakamura
- Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa da Misericórdia Do Rio de Janeiro, Rio de Janeiro, Brazil
- Centro de Estudos das Unhas (CEU), Santa Casa de Misericórdia Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Andreia Leverone
- Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa da Misericórdia Do Rio de Janeiro, Rio de Janeiro, Brazil
- Centro de Estudos das Unhas (CEU), Santa Casa de Misericórdia Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Flávia Costa
- DASA, Clínica Alta Excelência Diagnóstica, Rio de Janeiro, Brazil
| | - Bruna Duque Estrada
- Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa da Misericórdia Do Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Evidence-Based, Health of the Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Priscilla Haui
- Diagnósticos da América S/A, DASA, Avenida das Américas 4666, Sala 325, Rio de Janeiro, RJ, 22640-100, Brazil
| | - Flavio Luz
- Department of Dermatology, Universidade Federal Fluminense (UFF), Rio de Janeiro, Brazil
| | - Andre Fukunishi Yamada
- Department of Radiology, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
- Hospital Do Coração, HCOR, São Paulo, Brazil
| | - Heron Werner
- Diagnósticos da América S/A, DASA, Avenida das Américas 4666, Sala 325, Rio de Janeiro, RJ, 22640-100, Brazil
- Bio Design Laboratory, Pontifícia Universidade Católica (PUC-Rio), Rio de Janeiro, Brazil
| | - Clarissa Canella
- DASA, Clínica Alta Excelência Diagnóstica, Rio de Janeiro, Brazil
- Bio Design Laboratory, Pontifícia Universidade Católica (PUC-Rio), Rio de Janeiro, Brazil
- Department of Radiology of Universidade Federal Fluminense (UFF), Rio de Janeiro, Brazil
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Exley V, Jones K, O'Carroll G, Watson J, Backhouse M. 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. J Foot Ankle Res 2023; 16:55. [PMID: 37674170 PMCID: PMC10481456 DOI: 10.1186/s13047-023-00655-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/15/2023] [Indexed: 09/08/2023] Open
Abstract
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.
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Affiliation(s)
- Victoria Exley
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Katherine Jones
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Grace O'Carroll
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Judith Watson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Michael Backhouse
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
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Exley V, Jones K, O'Carroll G, Watson J, Backhouse M. A systematic review and meta-analysis of randomised controlled trials on surgical treatments for ingrown toenails part I: recurrence and relief of symptoms. J Foot Ankle Res 2023; 16:35. [PMID: 37301845 PMCID: PMC10257290 DOI: 10.1186/s13047-023-00631-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/18/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Ingrown toenails are a common nail pathology. When conservative treatments are ineffective, a surgical approach is often utilised. Despite recent narrative reviews, there is a need for an up-to-date and rigorous systematic review of surgical methods for treating ingrown toenails. 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 with a follow-up of at least 1 month. Two independent reviewers screened records, extracted data, assessed risk of bias and certainty of evidence. RESULTS Of 3,928 records identified, 36 (3,756 participants; 62.7% males) surgical interventions were included in the systematic review and 31 studies in the meta-analysis. There was very low quality evidence that using phenol with nail avulsion vs nail avulsion without phenol reduces the risk of recurrence (risk ratio [RR] 0.13 [95% CI 0.06 to 0.27], p < 0.001). No favourable effect was observed between chemical or surgical vs conservative management (0.55 [0.19 to 1.61], p = 0.280; 0.72 [0.33 to 1.56], p = 0.410), chemical or surgical vs other (e.g., CO2 laser, electrocautery) (1.61 [0.88 to 2.95], p = 0.120; 0.58 [0.25 to 1.37], p = 0.220), chemical vs surgical (0.75 [0.46 to 1.21], p = 0.230), surgical vs surgical (0.42 [0.21 to 0.85]), chemical vs chemical (0.19 [0.01 to 3.80], p = 0.280), surgical vs surgical + chemical (3.68 [0.20 to 67.35], p = 0.380), chemical vs surgical + chemical (1.92 [0.06 to 62.30], p = 0.710), local anaesthetic vs local anaesthetic + adrenaline (1.03 [0.22 to 4.86], p = 0.970), chemical timings 30 s vs 60 s (2.00 [0.19 to 21.41]) or antibiotics vs no antibiotics (0.54 [0.12 to 2.52], p = 0.430). Central toenail resection was the only procedure to significantly relieve symptoms (p = 0.001) but data were only available up to 8 weeks post-surgery. CONCLUSION Despite the high number of publications, the quality of research was poor and the conclusions that can be inferred from existing trials is limited. Phenolisation of the nail matrix appears to reduce the risk of recurrence following nail ablation, and with less certainty 1 min appears to be the optimum time for application. Despite this being a widely performed procedure there remains a lack of good quality evidence to guide practice.
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Affiliation(s)
- Victoria Exley
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Katherine Jones
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Grace O'Carroll
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Judith Watson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Michael Backhouse
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
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Gurhan U, Kahve Y, Yavuz IA, Varol A, Erler K. Does Electrocauterization of the Matrix After the Wedge Resection of the Toe-Nail Affect Recurrence in Discrete Age Groups Differently? A Retrospective Analysis. J Foot Ankle Surg 2023; 62:291-294. [PMID: 36182645 DOI: 10.1053/j.jfas.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/20/2022] [Accepted: 08/06/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Utku Gurhan
- Department of Orthopaedic Surgery, University of Kyrenia, Girne, TRNC.
| | - Yakup Kahve
- Department of Orthopaedic Surgery, Sungurlu State Hospital, Sungurlu/Çorum, Turkey
| | - Ibrahim Alper Yavuz
- Department of Orthopaedic Surgery, Eskisehir City Hospital, Eskisehir, Turkey
| | - Ali Varol
- Department of Orthopedic Surgery and Traumatology, Fatih Sultan Mehmet Education and Research Hospital, İstanbul, Türkiye
| | - Kaan Erler
- Department of Orthopaedics and Traumatology, Near East University, Nicosia TRNC
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Matushansky J, Wang Y, Chang MJ, Thomas C, Hockstein S, Lipner SR. Nail Changes during Pregnancy: A Cross-Sectional Survey of Patients at an Academic Center. Skin Appendage Disord 2023; 9:27-29. [PMID: 36643198 PMCID: PMC9833000 DOI: 10.1159/000526870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 08/18/2022] [Indexed: 01/04/2023] Open
Abstract
Introduction Physiological changes in skin and hair are common during pregnancy. There are limited data on nail changes during pregnancy. Therefore, our study objectives were to determine prevalence and types of nail changes in pregnant women. Methods A prospective study was conducted in the Weill Cornell Obstetrics and Gynecology waiting room, where a 32-question survey was administered to pregnant and nonpregnant patients. Results There was a total of 167 subjects (73 pregnant, 94 nonpregnant). Nail changes were reported by 25/73 (34.2%) and 12/94 (12.8%) pregnant and nonpregnant women, respectively (p < 0.05). Onychocryptosis and leukonychia were more common in pregnant (12.3% and 13.7%, respectively) versus nonpregnant women (5.3% and 0%, respectively) (p < 0.05). The majority of patients reported no changes in nail growth, thickness, brittleness, during their pregnancies. Discussion/Conclusion Most nail changes in pregnant and nonpregnant women are similar. Physicians should educate women that onychocryptosis and leukonychia are common and benign findings during pregnancy.
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Affiliation(s)
| | - Yu Wang
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Michelle J. Chang
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Charlene Thomas
- Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, New York, USA
| | - Steven Hockstein
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, New York, USA
| | - Shari R. Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, New York, USA
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7
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Fernández AN, Gómez-Carrión A, Zaragoza-García I, Sebastián CM, Wozniak PS, Lara AG, Saura-Sempere A, Sánchez-Gómez R. Management of post-surgical infection of onychocryptosis with topical application of hyaluronic acid versus antibacterial ointments. Heliyon 2022; 8:e10099. [PMID: 35992002 PMCID: PMC9389182 DOI: 10.1016/j.heliyon.2022.e10099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/03/2022] [Accepted: 07/25/2022] [Indexed: 10/27/2022] Open
Abstract
Introduction The prevention and cure of postoperative infections has been a source of study over the years and is currently being studied. In this bibliographic review, a comparison between the different products used for the prevention and treatment of postsurgical infections has been procured, likewise, being able to determine which would be the best option for the treatment of post-surgical infections. In this bibliographic review we focus on Onychocryptosis because it is an emerging problem today. Many surgeries are performed to fix this condition, which increases the risk of infections. Material databases, including PubMed and Cochrane Library, as well as websites of international organizations, were searched up to January 2021. The search included studies and trials in humans on the use of hyaluronic acid and antibacterial ointments in various conditions or diseases. Results 18 articles were analyzed individually, which included randomized studies of Hyaluronic Acid, various antibiotics and honey, and variables used topically. 3 articles were also selected to explain onychocryptosis and postoperative infections. Conclusion Despite being able to determine which antibiotic would be the best, and whether hyaluronic acid can be used for the prevention and/or cure of post-surgical infections, this review emphasizes that there is still a need for more specific studies on its use of these variables, both in post-surgical infections in general and in post-surgical onychocryptosis infections.
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Affiliation(s)
- Almudena Núñez Fernández
- Nursing Department, Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040, Spain
| | - Alvaro Gómez-Carrión
- Nursing Department, Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040, Spain
| | - Ignacio Zaragoza-García
- Nursing Department, Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040, Spain
| | - Carlos Martínez Sebastián
- Nursing Department, Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040, Spain
| | - Paola Sanz Wozniak
- Nursing Department, Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040, Spain
| | - Arturo Gómez Lara
- Nursing Department, Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040, Spain
| | - Arturo Saura-Sempere
- Nursing Department, Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040, Spain
| | - Rubén Sánchez-Gómez
- Nursing Department, Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040, Spain
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Oliveira F, Izquierdo-Cases JO, Martínez-Nova A, Contreras-Barragán E, Munuera-Martínez PV. The Modified versus the Conventional Winograd Technique for the Treatment of Onychocryptosis: A Retrospective Study. Int J Environ Res Public Health 2022; 19. [PMID: 35805476 DOI: 10.3390/ijerph19137818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/23/2022] [Accepted: 06/23/2022] [Indexed: 12/10/2022]
Abstract
The Winograd technique is a common surgical treatment for ingrown toenails. Attempting to improve the results of this technique, two modifications were adopted: the incisional approach and the use of adhesive approximation strips. This study aimed to compare the conventional technique and the modified version based on (i) postoperative complications, (ii) healing time, (iii) recurrence rate, and (iv) overall patient satisfaction. A longitudinal, observational, and retrospective design was used, with a sample of 208 patients divided into the modified Winograd technique (n = 111) and the conventional Winograd technique (n = 97) in three clinics in Portugal, with follow-up periods of more than 15 years and 10 years, respectively. The modifications to the Winograd technique revealed fewer postsurgical complications, in terms of infections (1.8% vs. 20.62%, p < 0.010), recurrence rate (2.7% vs. 5.21%, p > 0.05), shorter recovery time (8.10 ± 0.76 vs. 14.51 ± 3.48 days, p < 0.001), and lower postoperative pain and better satisfaction with the functional and esthetic results, with the patient’s overall satisfaction, and with significant differences in relation to the conventional technique (p < 0.001). The modifications performed showed a lower rate of infection, decreased healing time, and better patient satisfaction, suggesting that it may be adopted in clinical practice for the treatment of stages II and III ingrown toenails.
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Vinay K, Narayan V, Thakur V, Choudhary R, Narang T, Dogra S, Varthya SB. Efficacy and safety of phenol based partial matricectomy in treatment of onychocryptosis: A systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2021; 36:526-535. [PMID: 34913204 DOI: 10.1111/jdv.17871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/26/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Keshavamurthy Vinay
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India, 160012
| | - Vignesh Narayan
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India, 160012
| | - Vishal Thakur
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India, 160012.,Department of Dermatology, Venereology and Leprosy, Himalayan Institute of Medical Sciences, Dehradun, India, 248140
| | - Rajat Choudhary
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India, 160012
| | - Tarun Narang
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India, 160012
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India, 160012
| | - Shoban Babu Varthya
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, India, 342001
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10
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Moellhoff N, Polzer H, Baumbach SF, Kanz KG, Böcker W, Bogner-Flatz V. [Unguis incarnatus-conservative or operative treatment? A practical treatment algorithm]. Unfallchirurg 2021; 124:311-318. [PMID: 33111185 PMCID: PMC7985053 DOI: 10.1007/s00113-020-00903-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2020] [Indexed: 12/02/2022]
Abstract
Unguis incarnatus, an ingrown toenail, is a common condition in primary care, which is encountered by various medical professions. Inconsistent conservative treatment and nonindicated surgical treatment often result in complications and recurrence of the disease. Patients must be thoroughly informed about the complexity of the nail organ. This is a prerequisite to prevent trivialization of the disease and to achieve appropriate patient compliance for treatment. In this article a practical diagnostic and treatment algorithm for unguis incarnatus is presented. In mild cases of acute unguis incarnatus a consistent conservative treatment is the first-line strategy showing promising results. In cases of moderate to severe forms of acute unguis incarnatus, surgical procedures that preserve the nail matrix should be applied. For cases of chronic unguis incarnatus without an acute infection, elective partial matrixectomy can be indicated. Prior to any surgical intervention, detailed informed consent must be obtained from the patients.
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Affiliation(s)
- N Moellhoff
- Abteilung für Hand‑, Plastische und Ästhetische Chirurgie, Klinikum der Universität München, LMU München, Pettenkoferstr. 8a, 80336, München, Deutschland.
| | - H Polzer
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, LMU München, München, Deutschland
| | - S F Baumbach
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, LMU München, München, Deutschland
| | - K G Kanz
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - W Böcker
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, LMU München, München, Deutschland
| | - V Bogner-Flatz
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, LMU München, München, Deutschland
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Stewart CR, Algu L, Kamran R, Leveille CF, Abid K, Rae C, Lipner SR. Patient Satisfaction with Treatment for Onychocryptosis: A Systematic Review. Skin Appendage Disord 2020; 6:272-279. [PMID: 33088811 DOI: 10.1159/000508927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 05/15/2020] [Indexed: 01/30/2023] Open
Abstract
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.
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Affiliation(s)
| | - Leah Algu
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Rakhshan Kamran
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Cameron F Leveille
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Khizar Abid
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Charlene Rae
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, New York, USA
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Agarwal P, Kukrele R, Sharma D. In-growing toe nail results of segmental matrix excision. J Clin Orthop Trauma 2020; 11:S865-S870. [PMID: 32999570 PMCID: PMC7503063 DOI: 10.1016/j.jcot.2020.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION In-growing toenails commonly affect young men hampering the quality of life. There are many methods to treat in-growing toe nail but most of them have high recurrence rates and poor patient satisfaction. We describe our results of segmental matrix excision for correction of ingrowing toe nails. MATERIAL AND METHODS It is a retrospective study over a period of 2 years. Patients with symptomatic in-growing toe nails with stage II and III were operated by technique of segmental matrix excision. All patients were available for follow-up at ∼1 year. RESULTS 90 patients, 59 males and 31females with ingrowing nail of great toe (108 toes and 120 surgical sites) that underwent correction of by segmental matrix excision. Patient's age ranged from 19 to 59 years. There was involvement of right great toe in 42 patients, left great toe in 30 patients and bilateral toes in 18 patients. 12 great toes were affected on both sides (74 lateral sides and 46 medial sides of toes). 15/90 (16.6%) patients had history of previous failed surgery by nail plate avulsion. Complications include bleeding (n = 1), infection (n = 2). On average follow up of ∼1 year, there was only 1 recurrence. There was no loss of cutaneous innervation or osteomyelitis. All patients went back to their normal activity on 10th day. CONCLUSION Segmental matrix excision should be considered as the treatment of choice for ingrowing toe nail because of high cure rate, less pain, low risk of postoperative infection, and results in good cosmetic result.
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Affiliation(s)
- Pawan Agarwal
- Plastic Surgery Unit, Department of Surgery NSCB Government Medical College, Jabalpur, MP, 482003, India,Corresponding author. 292/293, Napier Town, Jabalpur, 482003, MP, India.
| | - Rajeev Kukrele
- Plastic Surgery Unit, Department of Surgery NSCB Government Medical College, Jabalpur, MP, 482003, India
| | - Dhananjaya Sharma
- Department of Surgery NSCB Government Medical College, Jabalpur, MP, 482003, India
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13
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Terrill AJ, Green KJ, Salerno A, Butterworth PA. Risk factors for infection following ingrowing toenail surgery: a retrospective cohort study. J Foot Ankle Res 2020; 13:48. [PMID: 32727511 PMCID: PMC7391500 DOI: 10.1186/s13047-020-00414-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Ingrowing toenails are a common and painful condition often requiring surgical management. Practitioners who perform surgery on ingrowing toenails include orthopaedic surgeons, general practitioners, podiatrists and podiatric surgeons. There has been limited investigation into the specific surgical approaches used by Australian podiatric surgeons for ingrowing toenails, or the associated infection rates for these procedures. The aim of this study was to assess the frequency and type of ingrowing toenail surgery performed by podiatric surgeons, and identify risk factors for post-operative infection. METHODS Data was entered into the Australian College Podiatric Surgeons (ACPS) National Audit Tool for all patients who underwent foot and ankle surgery performed by podiatric surgeons in Australia between January 2014 and December 2017. Infection within the first 30 days following surgery was recorded according to the ACPS national audit descriptors. Infection rates, risk ratios (RR) and 95% Confidence Intervals (CI) were calculated to determine postoperative infection risk. RESULTS Of 7682 records, 1831 reported 2712 diagnoses of ingrowing nails. Patients with a diagnosis of ingrowing toenails were younger, less likely to have systemic disease, and a lower proportion were female compared to those without ingrowing toenails. Furthermore, they were more likely to be diagnosed with a post-operative infection than those without ingrowing toenails (RR = 2.72; CI = 2.00-3.69; P < 0.01). Univariate risk factors for post-operative infection following ingrowing toenail surgery include age greater than 60 years (RR = 3.16; CI = 1.53-6.51; P < 0.01), surgery performed in an office setting (RR = 1.77; CI = 1.05-2.98; P = 0.04), and radical excision of toenail bed procedure (RR = 2.35; CI = 1.08-5.01; P = 0.04). Patients that underwent radical excision or office based procedures were on average older, and more likely to have systemic disease. Further, radical excision procedures were more likely to be performed in office base settings. CONCLUSIONS Ingrowing toenail surgery carries a greater risk of postoperative infection than other procedures performed by podiatric surgeons. Radical excision of toenail bed was associated with higher postoperative infection rates compared to other ingrowing toenail procedures. Procedures performed in an office setting carry a higher risk of infection. Further research into these associations is recommended.
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Affiliation(s)
- Alexander J Terrill
- School of Health and Human Sciences, Southern Cross University, Bilinga, 4225, Australia.
| | - Katie J Green
- School of Health and Human Sciences, Southern Cross University, Bilinga, 4225, Australia
| | | | - Paul A Butterworth
- School of Health and Human Sciences, Southern Cross University, Bilinga, 4225, Australia
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14
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Kilinc E, Buturak B, Alkan FA. Level of trace elements in serum and toenail samples of patients with onychocryptosis (ingrown toenail) and onychomycosis. J Trace Elem Med Biol 2020; 61:126509. [PMID: 32302924 DOI: 10.1016/j.jtemb.2020.126509] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 02/28/2020] [Accepted: 03/18/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Onychocryptosis (ingrown toenail) and onychomycosis are common pathologies of the toenail and affecting many people. Since levels of trace elements have been shown to vary in certain diseases, in the presented work, chromium (Cr), copper (Cu), iron (Fe), magnesium (Mg), manganese (Mn), selenium (Se), and zinc (Zn) levels of toenail and serum samples of healthy individuals and patients with onychocryptosis and onychomycosis were compared. METHODS Serum and toenail samples of 88 voluntary subjects (healthy n = 24; onychomycosis n = 24; onychocryptosis n = 40) aged between 19-80 years were collected. Levels of trace elements in the samples were analyzed by using an inductively coupled plasma-optical emission spectrophotometer (ICP-OES Thermo iCAP - 6000). The differences in medians between the groups for elements were evaluated with Kruskal -Wallis H test with post hoc for pairwise comparisons in SPSS 18. RESULTS Mg (p < 0.001) and Mn (p = 0.002) levels were significantly increased whereas Zn (p = 0.011) level was decreased in toenails of patients with onychomycosis compared to healthy subjects. Although Mg and Mn levels were higher in female subjects with onychomycosis (p = 0.001; p = 0.019), Mn was only increased in male subjects (p = 0.015). Mg was the only trace element found to be independent of sex, age, and smoking status in patients with onychomycosis. However, no significant difference has been found in serum trace element levels neither between any groups nor toenail trace element levels of patients with onychocryptosis and healthy subjects. CONCLUSION As a response of the human body to pathogens like fungi in toenails, Mg, Mn and Zn levels vary. Especially the role of Mg ions in onychomycosis needs to be investigated more specifically.
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Affiliation(s)
- Evren Kilinc
- Department of Biophysics, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Kayışdağı Caddesi No: 32, 34752, Ataşehir, Istanbul, Turkey.
| | - Birce Buturak
- Podology, Vocational School of Health Services, Acibadem Mehmet Ali Aydinlar University, Kayışdağı Caddesi No: 32, 34752, Ataşehir, Istanbul, Turkey
| | - Fatma Ates Alkan
- Department of Biophysics, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Kocamustafapaşa Cad. No: 34/E Fatih, Istanbul, Turkey
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Montesi S, Lazzarino AI, Galeone G, Palmieri R, Montesi M. The Recurrence of Onychocryptosis when Treated with Phenolization: Does Phenol Application Time Play a Role? A Follow-Up Study on 622 Procedures. Dermatology 2019; 235:323-326. [PMID: 31141805 DOI: 10.1159/000498849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 02/11/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Chemical matricectomy using phenol (CMP) is a recognized treatment option for onychocryptosis. However, the appropriate phenol application time to achieve nail matrix destruction is still unknown. Optimal ablation leads to low recurrence rates. The aim of this research was to assess the recurrence rate of onychocryptosis in a cohort of 622 consecutive patients treated with a 4-min CMP. METHODS We recruited all patients undergoing a 4-min CMP for onychocryptosis at the Istituto Podologico Italiano, Rome, Italy, in 2008-2017. Postoperative follow-up visits were set at 24 h, 7, 14, 21, and 28 days, 6 months, and 1 year after surgery. We used adjusted logistic regression to evaluate the potential risk factors for the disease recurrence including age, gender, toe shape, comorbidities, and disease localization. RESULTS The risk of recurrence in all patients treated with a 4-min CMP was 1.1% (n = 622, 95% CI = 0.5%-2.3%). In the subgroup of patients with cardiovascular disease (n = 39) the recurrence risk was 5.1% (95% CI = 0.61-7.3). Young age was also associated with increased odds of recurrence (p = 0.036). CONCLUSION In this observational study, 4 min with no interruptions seems to be the appropriate application time of phenol when using CMP for the treatment of onychocryptosis. A randomized controlled trial should be carried out to confirm our results.
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Mosquera-Fernández A, Díaz-Rodríguez M, González-Martín C, Platero-Arboiro M, Souto-Rey V, Balboa-Barreiro V. Hábitos podológicos en personas con alteraciones ungueales. GAC MED MEX 2018; 153:810-817. [PMID: 29414977 DOI: 10.24875/gmm.17003023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To determine the prevalence of onychocryptosis and onychomycosis confirmed by culture in subjects attending a Podiatric University Hospital and to describe their podiatric habits. Method Cross-sectional study of prevalence. The study was carried out at the Clinic University of Podology of A Coruna University (Ferrol, Spain). Review of 1082 clinical histories, of which 170 were selected, persons who had onychocryptosis diagnosed clinically. The presence of onychomycosis confirmed by cultivation, presence of onychocryptosis through clinical diagnosis and a questionnaire was handed out of podologic habits. Results Mean age of the total sample (n = 1082) was 47.9 ± 22.1 years. Prevalence of onychocryptosis was 15.7% (n = 170) with a mean age of 54.1 ± 20.1 years and with a significantly higher affectation in women and people under 65. Prevalence of onychomycosis was 17.6% (n = 30), mean age 59.5 ± 20.5 years with greater involvement in women and people over 65 years. With regard to the questionnaire of habits, the footwear more employee was the closed, cordoned off and heel flat. The majority of the subject came to a podiatrist for the first time; walked approximately 1 hour and their daily activity made of foot with short displacements. Conclusions A high prevalence of onychocryptosis and onychomycosis in people attending Podiatric services has been found. For its part using a type of flat or low heel and who does the care of toenails are shown as predictive variables of onychomycosis.
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Affiliation(s)
- Abián Mosquera-Fernández
- Departamento de Ciencias de la Salud, Facultad de Enfermería y Podología, Universidade da Coruña (UDC); Ferrol, A Coruña, España
| | | | - Cristina González-Martín
- Grupo de Investigación de Epidemiología Clínica, Departamento de Ciencias de la Salud, Facultad de Enfermería y Podología, UDC; Ferrol, A Coruña, España
| | | | - Victoriano Souto-Rey
- Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Ferrol (Área Sanitaria de Ferrol, España), Departamento de Ciencias de la Salud, Facultad de Enfermería y Podología, UDC; Ferrol, A Coruña, España
| | - Vanesa Balboa-Barreiro
- Grupo de Investigación de Epidemiología Clínica, Departamento de Ciencias de la Salud, Facultad de Enfermería y Podología, UDC; Ferrol, A Coruña, España
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17
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Correa J, Magliano J, Agorio C, Bazzano C. Super U Technique for Ingrown Nails. Actas Dermosifiliogr 2017; 108:438-44. [PMID: 28284420 DOI: 10.1016/j.ad.2017.01.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/10/2017] [Accepted: 01/13/2017] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Ingrown nails are a common problem, seen mostly in young adults. Also known as onychcrypotisis, this condition typically affects the great toenail. Four stages have been defined according to the severity and duration of the condition, and treatment varies from conservative to surgical techniques depending on the stage. We present our experience with this condition, describing the characteristics of our population and surgical treatment, in particular the super U technique. MATERIAL AND METHODS This was a retrospective, descriptive study of patients with ingrown great toenail treated surgically using the super U technique. We also describe postoperative management. RESULTS Ten patients with a mean age of 35.7 years underwent operation, 9 for unilateral ingrown great toenail and 1 for bilateral disease. Stage II ingrown nail was the most common. Half of the patients had been treated previously using other surgical techniques. The mean time to healing was 6 weeks. The only postoperative complication was infection in 1 patient. Mild to moderate postoperative pain persisted for a week. The majority of patients were satisfied with the cosmetic result. CONCLUSIONS We believe the super U technique is very useful in stage II ingrown nail and in disease that has recurred after previous surgery, and is the treatment of choice in stage III or IV disease in which excessive hypertrophic tissue is found.
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Abstract
Paronychia is an inflammation of the tissues alongside the nail. It may be acute or chronic and can be seen in isolation or in association with an ingrowing toenail. Acute paronychial infections develop when a disruption occurs between the seal of the nail fold and the nail plate, providing a portal of entry for invading organisms. The treatment of paronychia associated with an ingrowing toenail is aimed at treating the causal toenail. In paronychia not associated with an ingrowing toenail, antibiotics may cure an early infection but surgical drainage of an abscess is often required. In this case, an intra-sulcal approach is preferable to a nail fold incision. Chronic paronychia is less common in the feet than in the hands. It is a form of contact dermatitis and is frequently non-infective, however the chronically irritated tissue may become secondarily colonised by fungi. A dermatology consultation should be obtained for suspected chronic paronychia. Patients with chronic paronychia that is unresponsive to standard treatment should be investigated for unusual causes, such as malignancy. An algorithm for the treatment of paronychia is presented in this review.
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Affiliation(s)
- Adam Lomax
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, United Kingdom.
| | - James Thornton
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, United Kingdom
| | - Dishan Singh
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, United Kingdom
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Abstract
Disorders of the dermis and the nails on the feet are common. Despite the simplicity of the skin and nail disorders of the foot, they can be debilitating and impact the patient's ability to ambulate and perform activities of daily living. Diagnosis in most cases is confirmed on physical examination alone. Diligent care of skin and nail disorders can prevent further pathology involving the deeper structures of the foot and allow the patient to fully participate in their usual activities.
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Affiliation(s)
- Wesley W Flint
- Department of Orthopaedics, Penn State Hershey Medical Center, Penn State Bone and Joint Institute, 30 Hope Drive, Hershey, PA 17033, USA
| | - Jarrett D Cain
- Department of Orthopaedics, Penn State Hershey Medical Center, Penn State Bone and Joint Institute, 30 Hope Drive, Hershey, PA 17033, USA.
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Zavala Aguilar K, Gutiérrez Pineda F, Bozalongo de Aragón E. [Management of onychocryptosis in primary care: A clinical case]. Semergen 2013; 39:e38-40. [PMID: 24034767 DOI: 10.1016/j.semerg.2012.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 05/06/2012] [Indexed: 12/01/2022]
Abstract
Onychocryptosis (ingrown toenail) is a condition commonly seen in Primary Care clinics. It is uncomfortable and restrictive for patients and has a high incidence in males between second and third decades of life. It is of unknown origin, with a number of predisposing triggering factors being involved. Treatment depends on the stage of the ingrown nail and the procedures may range from conservative to minor surgery that can be performed by the Primary Care physician in the health centre. We report the case of a 25-year onychocryptosis that did not respond to conservative management, and was extracted with partial matricectomy of the nail.
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Affiliation(s)
- K Zavala Aguilar
- Medicina de Familia y Comunitaria, Centro de Salud Cascajos, Logroño, España.
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