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) | |
| Symptoms | nail 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. |
| Treatment | Conservativenail 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. |
| Unresolved | stage 1 will progress to stage 2 then stage 3. |
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?
- 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.
- Regrowth – 3% More common on bilateral feet procedures, surgery can be offered again.
- Anaesthetic reaction – rare. anaphylaxis . We are fully trained.
- Phenol Burn – rare. We will monitor and work with you to manage these skin changes.
- 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.
