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What can I expect from an ingrown toenail surgery appointment?

Ingrown toenail surgery

Article 3 – ingrown nail series

At an ingrown toenail surgery appointment you will see a qualified podiatrist who will assess, stage, diagnose, treat, offer advice and a treatment plan based on your medical conditions, background and medication.

Assessment for ingrown toenail surgery

Your podiatrist will assess your toenail, including the severity of your ingrowing nail and discuss the treatment options available. 

Part of the assessment will be differential diagnosis, such as:

  • subungual exostosis
  • pyogenic granuloma
  • subungual verruca
  • glomus tumour
  • nail unit tumours
  • inclusion cysts.

What stage is my ingrown toenail?

When you see the podiatrist, they will examine and assess the ingrown nail, they will often let you know what stage it is, in order to guide you with treatment options. Ingrown toenails are not self limiting, which means if it is NOT treated it will progress through all the stages.

Stage 1 (Mild)Stage 2 (Moderate)Stage 3 (Severe)
Symptomsnail fold swelling
oedema
erythema
pain with direct pressure. 
as stage 1
granulation tissue, within & local to the affected nail fold
pus pocket formation (paronychia) 
discharge (ulcer formation)
localised infection
pain local nail fold hypertrophy
as stages 1 & 2
signs of long-standing chronic inflammation
epithelialisation of the granulation tissue
chronic infection
discharge from the affected sulcus
localised nail lysis
marked nail fold & generalised swelling of the affected toe. 
TreatmentConservativenail resectionuse of nail packingadvice on nail care & footwear Nail surgery (partial or total)  with phenolisation under local anaesthetic.Nail surgery (partial or total)  with phenolisation under local anaesthetic.
Unresolvedstage 1 will progress to stage 2 then stage 3. 
Stage of ingrown nail and treatments

What is conservative Treatment?

Conservative treatment means non surgical treatment. This includes nail resection (cutting back) to remove the nail spicule or reduce the nail width temporarily. If the toe is infected, antibiotics may be given, but once the nail spicule has been removed, daily wound care should allow natural healing. This is the case for stage 1 as above. 

The podiatrist would give you advice about how to best look after your toenails going forward, they may demonstrate how to cut your nails, what tools to use and what to do should it worsen.

Ingrown toenail surgery

Ingrown toenail surgery (Nail surgery) is a treatment carried out by medical specialists such as podiatrists, and also by general practitioners, podiatric and orthopaedic surgeons.

It is a common procedure throughout the world. It is a treatment for pathological nail conditions but is most commonly used to treat ingrown toenails (onychocryptosis). 

For nails that repeatedly grow in, the option to remove part of all of the nail (partial nail avulsion/total nail avulsion) under a local anaesthetic is recommended.

It is recommended that phenol is used during the surgical procedure to permanently cauterise the nail cells to prevent nail regrowth at the edges. (A Cochrane review found that surgical treatments were more effective than non-surgical treatments).

Do you have to keep up to date?

Podiatrists are trained and registered to carry our nail surgery and they must keep their skills up to date through annual training in Basic Life Support (BLS) and triennial courses to update them in the use and administration of Local Anaesthetics (LAs) and other prescription-only medicines (POMs) .

What can I expect when I have ingrown toenail surgery at Zest?

Nail Surgery – Partial/Total Nail Avulsion with phenolisation

Do I have to go to a theatre or hospital to have this done?

Toenail surgery is performed in our podiatry clinic in Oxford, with follow up appointments the day after surgery and 4 weeks later. The procedure is done under a local anaesthetic, enabling a quick recovery. We work with aseptic /sterile techniques to ensure infection control.

Will I need an injection?

The toes need to be numb in order to perform the treatment, we must inject both sides of the offending toe(s) at the base. This can take from 5-20 minutes to become fully numb, and shall remain numb up to 2 hours.

In order to ease any discomfort and to help those who are needle phobic, an icepack can be applied to the toe beforehand or we can apply cutaneous vibration. (Cutaneous vibration can help stimulate interneurons in the spinal cord, down regulating the activity in the pain conducting fibres)

How much nail do you take away?

The amount of nail removed depends on how severe the problem is. For a partial avulsion only the side(s) of the nail are removed, this can be one side or both depending on how ingrown the nail is, occasionally we may decide to take the whole nail, this is a total avulsion. This is fully discussed at the initial appointment, where we agree a plan. Phenol is applied to the base of the nail plate to cauterise the nail to prevent regrowth.

On your first return the wound is checked and the dressing replaced to a smaller plaster style dressing to allow for comfort and a gradual return to normal activities, you shall be given guidance on how to manage the toe(s) as it heals

What do I need if I’m having ingrown toenail surgery?

  • Appropriate shoes to wear home (flip flops/slidders)
  • A lift home or taxi – you cannot drive
  • Had food and drink before you arrive
  • Update us on any medical changes since your pre operative appointment
  • Have paracetamol incase of mild discomfort (if suitable to take)
  • Plan a few hours of rest after surgery to allow initial healing

What are the risks of ingrown toenail surgery?

  1. Infection – most common. The toe may be infected when it arrives for surgery, and the use of phenol means the wound is present for longer, thus higher risk. We use aseptic techniques throughout the procedure and can supply antibiotics if appropriate.
  2. Regrowth – 3% More common on bilateral feet procedures, surgery can be offered again.
  3. Anaesthetic reaction – rare. anaphylaxis . We are fully trained.
  4. Phenol Burn – rare. We will monitor and work with you to manage these skin changes.
  5. Nerve irritation/damage – rare. We are trained in local anaesthetic and will work to perform at the highest standard.

How does the toenail not grow back?

Phenolisation is the term used for the chemical ablation that podiatrists apply to the nail matrix to prevent it from growing back, 97% do NOT grow back. If you are having a partial nail surgery, it will only be applied to the side, not the whole nail. We will assess if you are suitable for chemical ablation. 

If healing capacity is reduced we may recommend a surgical procedure without the chemical known as Winograd or Zadeks procedure, performed by a Podiatric surgeon or an orthopaedic consultant.

How do I look after my toenail after surgery?

Pain is often less after the procedure as the chemical we put on (phenol) helps to reduce the pain and acts like an antiseptic. The action of phenol is to cauterise the nail matrix epithelial tissue and as such this causes some oozing for approximately 14 days.

It is recommended that you soak the toe in saline and change the dressings daily at home and we see you in the clinic again in 4 weeks to check progress and agree discharge.

Should you have any concerns or get any post operative infection we can manage this and provide antibiotics and additional wound care, as necessary please contact us, don’t wait.

I think ingrown toenail surgery is right for me, what should I do?

If you feel this is the right treatment for you, please contact us or book in for an initial consultation, if we are in agreement we can get you booked in at a suitable time. Don’t wait as it will not improve without help.

Ingrown nail series Articles

Do I have an ingrown toenail?

ingrown toenail

Article 2 – ingrown nail series

An ingrown toenail occurs where a piece of nail pierces the flesh of the toe. It can be painful on use, in shoes and when in bed with the covers on it. It affects around 10,000 people per year in the UK, of which 20% of GP foot appointments are due in ingrown toenails.

Who gets ingrown toenails?

It is seen in every age group but is common amongst adolescents with a higher incidence in males. Adolescents are common due to incorrect nail cutting, picking, sports such as football and ill fitting shoes (feet grow faster than shoes replaced). Adults get changes in foot shape due to arthritis or nail condition such as fungal infections, and some are long term sufferers, not realising that nail surgery can correct the condition.

Ingrown toenails are thought to be caused most commonly by trauma and poor nail cutting technique but ill-fitting footwear, excessive sweating, poor hygiene, biomechanical factors and obesity can all contribute. Systemic disease, the aging process and congenital malformation are also causative factors. 

What can go wrong?

The first toe is the most common site, but lesser toes can also be affected. The condition ranges from mild, which can be treated conservatively, to progressively more painful stages which need surgical measures to resolve.

It often presents with pain on the side or the top of the nail. Bacterial infections are common, especially if the nail is ingrown for a while. 

If the nail remains grown into the skin, it means there is an open wound, even if you cannot see it. The body will attempt to close this hole by producing more tissue, this can build up next to the hole and become painful. It is known as hypergranulation tissue. This process makes the ingrown nail worse as the toe becomes enlarged and struggles to sit comfortably in a shoe. 

This will impede walking and the ability to wear certain footwear affecting daily working and social life.

What can I do to help my ingrown toenails?

Regular toenail care

  • Cut your nails regularly
  • It is best to cut after a bath or shower as it will make them softer
  • Use nail nippers not scissors
  • Cut straight across, leaving the corner of the nail visible if possible
  • Wash your feet daily, and change your socks daily
  • Wear well fitted footwear
  • Have children measured regularly
  • Avoid footwear made by man-made materials (synthetics) 
  • Choose socks and shoes of natural fibre
  • Be cautious when cutting if you have long term conditions such as diabetes, are taking steroids or are on anticoagulants
  • Do NOT remove spikes of nails yourself – seek a podiatrist
  • If you have a PAINFUL toenail – seek a podiatrist
  • Are concerned or worried – seek a podiatrist
  • In the case of any symptoms of a bacterial infection – seek a podiatrist

When the toenail is painful

Things that will help before you see the podiatrist:

  • Bathe your toes – relieves discomfort and helps to clean the toes
    • Use warm water – not HOT or COLD
    • Dissolve a spoon of salt into boiling water then add cool water
    • Soak for 2-3 minutes
    • Leave to dry before adding a dressing
  • Apply a sterile dressing – this will help to keep out dirt and minimise infection
  • Wear footwear that will accommodate your toe with a dressing
  • Avoid high impact sport whilst the toe is very painful (squash or climbing)
  • Avoid adding creams to the toenails as bacteria may grow in it.
  • Remove all nail varnish, the body treats it as a foreign object and may react worse.
  • We advocate the use of clinisept+ LINK
  • Order a nail care pack from us

For any patients that have foot care issues that do not resolve themselves naturally or through routine foot care within two weeks, it is recommended that you seek the help of a podiatrist

Will antibiotics get rid of my ingrown toenail?

Antibiotics will help with the bacterial infection from the ingrown nail, it will help reduce inflammation and may reduce your pain. These are symptoms, the nail unless removed will remain in the toe and will continue to cause you pain. You must treat the cause as well as the symptom. Antibiotics on their own will not get rid of your ingrown toenail.

What treatment is available for ingrown toenails?

Podiatrists treat ingrown toenails daily. The severity of the ingrown toenail would be assessed and treatment options offered accordingly. 

These may include a small removal of offending nail (nail resection) or nail spike (nail spicule).

This treatment may not require anaesthetic and advice about long term treatment would be given including cutting and footwear.

Should the toenail be at a more severe stage that requires long term nail removal this will be advised. Long term includes the use of a chemical to prevent it growing back. The podiatrist will suggest this if they feel the nail is beyond regular management. The surgery known as Nail Avulsion is often a side (partial) removal of the nail and if required a total nail removal. This would be with local anaesthetic. It has a success rate of 97% in the UK when actioned by a podiatrist.

As podiatrists we are able to manage infected toes with antibiotics and administer all foot anaesthetics within our clinics. If you think you have an ingrown toenail please contact us we can help you at Zest Podiatry & Physio, alternatively you can book online.

Ingrown nail series Articles

Why do my toes and toenails hurt?

toenails hurt

Article 1 – ingrown nail series

Toes and toenails hurt for a number of reasons, the most common causes include ingrown toenails, bunions, cuts or scrapes, blisters, corns and calluses, infections and trauma or injury. Toe joint pain can include arthritis such as rheumatoid arthritis, gout, osteoarthritis. Further information found at foot, ankle and leg pain.

The toenail

The toenails are thickened extensions of the top layer of our skin and are made of the same tough protein, called keratin. We have them on the end of all of our toes. The purpose of a toenail is to protect the distal soft tissues of toes from physical trauma of everyday life. 

Anatomy of a toe

When we look at our toes the most visible part is known as the nail plate. At the top of the nail is soft tissue surrounding and protecting it called a cuticle. Beneath the nail plate is our nail bed, and beneath the cuticle is the matrix. The matrix is composed of living cells that produce keratin. The keratin forms the nail cells. All of this is closely connected to the blood vessels and numerous nerves of the nail bed.

Why do my toenails hurt?

Toenails hurt when the shape, condition or position of them affects the toe. For example, if you were to sit with a thick book on your head it would hurt after a while, the same can be said for pressure on a toe from a thickened nail. 

Toenails hurt due to nail shape and texture

  • Ingrown nails causing long term pain and possible infection
  • Involution causing ingrown nails leading to bacterial infections
  • Flat causing ingrown nails leading to bacterial infections
  • Thickened causing pain from pressure as it gets thicker
  • Splitting, peeling, or brittle nails

Toenails hurt due to the condition of the nail

  • Fungal infection causing thickening or/and involution
  • Picked or bitten can lead to ingrown nails and infection
  • Trauma such as stubbing or dropping something on it
  • Micro trauma such as running with long nails or running down hill
  • Separation from the nail bed
  • Chemotherapy drug changes to nails
  • Nail changes from psoriasis, peripheral arterial disease and others conditions

Why do my toenails look different to others?

The shape of the nail is determined by the shape of the bone in the toe; however the nail shape can be influenced by other factors such as skin conditions, infections, trauma, medicines, systemic illnesses.

  • Detachment (onycholysis) can be affected by excess keratin, inflammatory changes or infection
  • Thickening may occur as a result of inflammatory, traumatic and infective conditions, nail bed thickening
  • Clubbing of nails can be caused by low oxygen levels in the body in chronic lung conditions
  • Concave nails.This occurs when body is deficient of iron 
  • Pitting can be a sign of Psoriasis
  • Discolouration can be caused by trauma, infective conditions and cancer OR nail varnish damage
  • Ridging (transverse, longitudinal)
  • Ingrown due to nail shape, trauma, poor footwear

What should I do if I am worried about my toenails or if the toenails hurt?

Podiatrists are the foot and ankle experts. We study dermatology of the feet and the nails in particular. We can diagnose, advise and treat a range of nail conditions including nail surgery with local anaesthetic.

At Zest Podiatry & Physio we pride ourselves in being able to help with many nail conditions, we are experts in nail surgery and are always happy to help you. Contact us or book an initial appointment online.

Ingrown nail series Articles

Toenails case study

toenails case study

Case Study

Ingrown sore toenails: Phoebe aged 17 years. Fit and healthy. No previous nail conditions.

In April 2019 Phoebe spent 4 days walking in the Peak District for her gold DofE. She walked 10-15 km per day over a range of terrains.

  • Day 1 she experienced some pain, blisters started to form and the toes started to hurt. Phoebe added dressings to prevent some of the rubbing.
  • Day 2 the nails ached at night and were sore (bruised).
  • Day 3 she found that the toenails became very painful and sore whilst walking, and they started to show signs of bleeding. Some of the blisters had popped. 
  • Day 4 the toes bled and were so painful that she had to use paracetamol to help with the ingrown sore nails.

After the expedition

Phoebe came to see us not long after she got back. The big toenails were bruised. She had cut her nails, and the wounds from the blisters were healing. We advised salt water bathing daily and to avoid any tight footwear or impact sports for the next week. We advised that she may lose the toenails, and to monitor them.

Tips for healthy toenails on expeditions

  • Check that your boots fit and comfortable before your trip
  • Wear appropriate socks for the weather and terrain
  • Cut your toenails before leaving home
  • Take dressings and blister plasters with you

6 months later

In September Phoebe came back to see us as both big toes were giving her some pain, down the sides of the nails and if any pressure was applied to them. It made sports and activities hard work. They were ingrown sore toenails.

She had not lost the nails; however they were both now growing into the skin and were causing pain. After cutting them back and monitoring for a further month, Phoebe decided to have nail surgery.

Nail Surgery for ingrown sore toenails

Podiatrists are able to perform nail surgery. They are trained during their podiatry degree, for more information on nail surgery please check out the information on the college of podiatry website.

Nail surgery involves either part or all of the nail being removed. We always try and do part if possible (sides), and in most cases we do. Sometimes only one side is necessary. We do this whilst your toe is numb from local anaesthetic, much like the dentist with fillings in your mouth.

We cut the ingrown sore nails away, then a chemical is applied called phenol which destroys the nail bed and stops it growing back. The result is a slimmer nail, that doesn’t grow in and or cause pain. The nail takes around 3-4 weeks to heal, however the pain is normally reduced the following day. 

Phoebe update

One month after surgery, the nails were checked and Phoebe confirms she is still in no pain from her toenails.

Nail surgery with phenol works in 97% of cases

To find out more about ingrown sore nails and nail surgery at Zest Podiatry, click here.

Make Your Appointment Today

To book your appointment with Zest Podiatry & Physio book online, call us or contact us for further details.

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What is Podiatry?

musculoskeletal

Podiatrists are foot healthcare experts.

They are university trained to prevent, diagnose, treat and rehabilitate medical and surgical conditions of the feet and lower limbs. The College of Podiatry.

Podiatrists (formerly named Chiropodists) are the healthcare professionals responsible for delivering podiatry both in hospital and clinic settings. They study a degree course and are registered with the HCPC (Health Care Professions Council).

They deal with a broad range of conditions that affect the foot and ankle. Treatments include specialist treatments such as swift microwave verrucae therapy, sports podiatry, injection therapy, musculoskeletal and nail surgery.

Foot health provision is available on the NHS to those who long term conditions that affect their feet. Conditions may include Diabetes, Peripheral Arterial Disease and Rheumatoid Arthritis (NICE guidelines).

We have 3 full-time and 2 part-time podiatrists who are able to provide general podiatry alongside musculoskeletal. We treat those in pain, have reduced mobility or just want to improve aesthetics. Musculoskeletal podiatry includes the use of ultrasound imaging, injection therapy, extracorporeal shockwave therapy (ESWT), Run3D and orthoses.

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