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Ingrown toenail facts

An ingrown toenail is a common condition often seen in the big toenail.

Athletes commonly suffer from ingrown toenails

Improper shoe gear and toe injuries are commonly associated with ingrown toenails.

It is not uncommon for an ingrown toenail to recur.

Conservative treatments include soaks, elevation, and good foot hygiene. Medical treatment is not always required. Oral antibiotics are sometimes required as a treatment. Sometimes minor toenail surgery is required.

What are ingrown toenails?

An ingrown toenail is caused by the pressure from the ingrowth of the nail edge into the skin of the toe. Once the edge of the nail breaks through the skin, it produces inflammation. Initially presenting as a minor discomfort, it may progress into an infection in the adjacent skin (cellulitis) and/or become a reoccurring problem. Ingrown toenails most commonly affect the large (great) toes. An ingrown toenail is medically referred to as onychocryptosis.

Ingrown nails — when the nail grows into the flesh instead of over it — usually affect the toenails, particularly the big toe. People with curved or thick nails are most susceptible, although anyone can suffer from ingrown nails as a result of an injury, poorly fitting shoes, or improper grooming of the feet. People with diabetes, vascular problems, or numbness in the toes need to be aggressive in treating and preventing ingrown toenails because they can lead to serious complications, including the risk of losing a limb.

A damaged or improperly trimmed nail can become ingrown, burrowing into the skin at the side of the nail. The site can become painful and infected, and may not heal until the nail is removed. To avoid ingrown nails, always trim nails straight across.

What Causes Ingrown Nails?

Ingrown nails are most frequently caused by cutting your toenails too short or rounding the nail edges or by wearing ill-fitting shoes or tight hosiery that press the nail into your toe. You can also develop an ingrown nail after an injury, such as stubbing or jamming your toe.

If the condition causing the ingrown toenail continues, overgrowth of the tissue over the nail can lead to permanent changes in the tissue that can cause infection, more pain, and more swelling.

When a toenail is ingrown, it is curved and grows into the skin, usually at the nail borders (the sides of the nail). This “digging in” of the nail irritates the skin, often creating pain, redness, swelling, and warmth in the toe.

If an ingrown nail causes a break in the skin, bacteria may enter and cause an infection in the area, which is often marked by drainage and a foul odor. However, even if the toe isn’t painful, red, swollen, or warm, a nail that curves downward into the skin can progress to an infection.

Causes
Causes of ingrown toenails include:

Heredity. In many people, the tendency for ingrown toenails is inherited.

Trauma. Sometimes an ingrown toenail is the result of trauma, such as stubbing your toe, having an object fall on your toe, or engaging in activities that involve repeated pressure on the toes, such as kicking or running.

Improper trimming. The most common cause of ingrown toenails is cutting your nails too short. This encourages the skin next to the nail to fold over the nail.

Improperly sized footwear. Ingrown toenails can result from wearing socks and shoes that are tight or short.

Nail Conditions. Ingrown toenails can be caused by nail problems, such as fungal infections or losing a nail due to trauma.

What are the symptoms and signs of an ingrown toenail?

Ingrown toenail symptoms and signs include redness, pain, and swelling. Sometimes there may be a clear yellowish drainage, or if it becomes infected, pus drainage. Occasionally, ingrown toenails resolve without treatment. Painful, persistent, and recurring ingrown toenails should be treated by a podiatrist.

What causes ingrown toenails?

The main causes of an ingrown toenail are improper trimming of the toenail, an inherited or hereditary condition, and improper shoe fitting. Injury and nail picking are also common causes.

Are some people more prone to ingrown toenails?

There are a number of risk factors that may predispose a person to having an ingrown toenail. The following are some of the more common:

Athletics, particularly stop and start sports such as tennis, soccer, and basketball

Improper shoe gear that is either too small or too large

Repetitive pressure or trauma to the feet

Poor foot hygiene

Abnormal gait

Foot or toe deformities, such as bunions and hammertoes

Congenital toenail deformity

Abnormally long toes

Obesity

Diabetes

Fungus infection of the nails (onychomycosis)

Arthritis

Soft tissue or bony tumors of the toes

Hyperhidrosis (excessive sweating of the feet)

Edema of the lower extremities

Which nails are most commonly affected by ingrown toenails?

Ingrown toenails most commonly occur in the large or “great toes.” However, any of the toenails can be affected on either border or side.

What causes infections in ingrown toenails?

The warm, moist environment of the feet can be a breeding ground for bacteria and fungi. These commonly include Staphylococcus,Pseudomonas, dermatophytes, Candida, and Trichophyton. When there is a break in the skin from the offending nail border, these organisms can invade the area and cause an infection. Treatment for these infections is essential to maintain healthy toenails and feet.

How do physicians diagnose an ingrown toenail?

The diagnosis of an ingrown toenail is typically straightforward. However, the signs and symptoms of ingrown toenails can vary quite dramatically, particularly if an infection develops. There may simply be some tenderness at the nail border when pressure is applied. There is typically an incurvation of the nail or a spike of nail (spicule) pressing into the skin of the nail border. Associated redness and swelling localized to the nail also suggest the diagnosis of an ingrown toenail. When an infection is involved, there may be severe redness and swelling, drainage, pus, and malodor.

Making the proper diagnosis requires taking into account the medical history and all possible causative factors. If you are unsure, seek professional help. Some conditions such as tumors, foreign bodies, trauma, and fungal infection may appear to be an ingrown toenail to the untrained eye.

What are possible complications of ingrown toenails?

An unresolving ingrown toenail can have serious consequences. A localized infection of the nail border (paronychia) can progress to a deeper soft-tissue infection (cellulitis) which can in turn progress to a bone infection (osteomyelitis). Complications can include scarring of the surrounding skin and nail borders as well as thickened, deformed (onychodystrophy) fungal toenails (onychomycosis).

How do people treat an ingrown toenail at home?

The following home-care treatments may provide temporary relief.

Lukewarm water foot soaks for 15 to 20 minutes with any one of the following options can be helpful: one part white vinegar to four parts water; 2 tablespoons Epsom salts per quart of water; or dilute Clorox type bleach with 1/3 teaspoon of Clorox in 1 gallon of water.

Elevate the foot and leg.

Take oral anti-inflammatory drugs.

Trim the toenail straight across the top without digging into the corners or leaving them too short.

Carefully rolling back be overgrown skin at the affected nail border may allow one to slip a small piece of cotton or dental floss to lift the offending edge of the nail up from the skin.

If symptoms persist, medical treatment from a podiatrist is recommended.

When should someone seek medical treatment for an ingrown toenail?

Persons with diabetes or those who have a compromised immune system should promptly seek the care of a podiatrist/physician for ingrown toenail treatment. If home treatments are not successful within a week or there is persistent pain and/or signs of infection, podiatric medical treatment is recommended. Signs of infection can include swelling, redness, streaking, pain, and drainage that may be yellow, green, or white and purulent (containing pus).

What kind of doctor treats ingrown toenails?

Although many types of doctors, including family physicians, pediatricians, urgent care walk-in physicians, and dermatologists, can treat ingrown toenails, podiatrists are uniquely qualified among the medical professionals to treat this condition.

What is the treatment for ingrown toenails?

There are various types of treatments, including self-care, soaking, avoidance of shoe pressure on the toenails, proper methods to trim the nails, and various surgical treatments. Sometimes antibiotics may be required. 

What types of nail surgery are used for ingrown toenails?

Surgical treatments include the following: temporary section of the offending nail border or corner, avulsion (detachment) of the nail or offending nail border, or permanent elimination of the nail (matrixectomy) or offending nail border (partial matrixectomy). A matrixectomy is the destruction or removal the cells where the nail grows from called the nail matrix. The nail matrix is at the base of the toenail under the skin. This procedure can be done surgically by dissection, chemically, or electrically by destroying part or all of the matrix cells. These procedures are commonly reserved for chronic or recurrent situations.

Is surgery really necessary?

If conservative treatments fail, surgery to remove the offending nail border is recommended. If the condition is recurrent and/or chronic, a matrixectomy may be recommended.

How can people prevent ingrown toenails from recurring?

Avoid shoes that are too small (putting pressure on the toenail) or too large (where the foot is moving back-and-forth inside the shoe. Improperly fitting footwear can cause trauma to the toenail. Use proper methods of trimming the toenail with clean instruments and do not trim them too short.

Ingrown toenail do’s

Do wear properly fitting shoes that allow you to wiggle your toes without having your foot slide around within.

Do avoid repeated pressure and trauma to the toenails.

Do wear sport-specific shoes.

Do practice good foot hygiene.

Do trim toenails straight across.

Ingrown toenail dont’s

Don’t cut down the corners of the toenails.

Don’t trim toenails too short.

Don’t wear improperly fitting shoes.

Don’t avoid treatment by a professional if symptoms persist.

Don’t try and do surgery on the toenail yourself.

Treatment
Sometimes initial treatment for ingrown toenails can be safely performed at home. However, home treatment is strongly discouraged if an infection is suspected, or for those who have medical conditions that put feet at high risk, such as diabetes, nerve damage in the foot, or poor circulation.

Home care:
If you don’t have an infection or any of the above medical conditions, you can soak your foot in room-temperature water (adding Epsom’s salt may be recommended by your doctor), and gently massage the side of the nail fold to help reduce the inflammation.

Avoid attempting “bathroom surgery.” Repeated cutting of the nail can cause the condition to worsen over time. If your symptoms fail to improve, it’s time to see a foot and ankle surgeon.

Physician care:
After examining the toe, the foot and ankle surgeon will select the treatment best suited for you. If an infection is present, an oral antibiotic may be prescribed.

Sometimes a minor surgical procedure, often performed in the office, will ease the pain and remove the offending nail. After applying a local anesthetic, the doctor removes part of the nail’s side border. Some nails may become ingrown again, requiring removal of the nail root.

Following the nail procedure, a light bandage will be applied. Most people experience very little pain after surgery and may resume normal activity the next day. If your surgeon has prescribed an oral antibiotic, be sure to take all the medication, even if your symptoms have improved.

Preventing Ingrown Toenails
Many cases of ingrown toenails may be prevented by:

Proper trimming. Cut toenails in a fairly straight line, and don’t cut them too short. You should be able to get your fingernail under the sides and end of the nail.

Well-fitted shoes and socks. Don’t wear shoes that are short or tight in the toe area. Avoid shoes that are loose, because they too cause pressure on the toes, especially when running or walking briskly.

When to seek medical care

Any time an ingrown toenail has developed into an infection (drainage, a fever, lighter skin surrounded by red skin, or worsening pain and swelling), seek medical advice.

Even if the ingrown toenail is only inflamed without infection, seek medical advice if the following conditions also occur:

If you have incomplete primary immunisation for tetanus or have not had your booster tetanus immunisations, then you need to discuss your tetanus status.

If there is no improvement after three days of home care.

If you are a diabetic, have poor circulation, HIV/AIDS, are on chemotherapy or have another reason for poor healing or increased risk of infection.

Examinations and tests

The doctor will decide if an infection is present or not and how intensively to treat it.

The doctor will evaluate your ingrown toenail by asking how the problem developed (if any injury, when it started) and about other medical problems, medication taken, allergies and most recent tetanus immunisation.

A physical examination will include checking temperature, pulse and blood pressure, a detailed examination of the foot, toenail and the lymph nodes in the groin, and possibly an X-ray of the foot.

Blood tests may be performed if you have a severe infection or a history of diabetes.

Ingrown toenails treatment self-care at home

If it is early in the course of the ingrown toenail, then home care may be successful in preventing the need for surgery.

Soak the foot in warm water four times a day. You do not need to add soap or antibacterial agents to the water.

Wash the foot, including the affected area, twice a day with soap and water. Keep the foot clean and dry during the rest of the day.

Do not wear high heels or tight-fitting shoes. Consider wearing sandals, if appropriate, until the condition clears up.

Try to lift up the corner of the nail that is digging into the skin. Take a small piece of cotton or gauze and roll it between your fingers to form a small roll or wick. Then place the roll between the nail and the skin to keep it elevated. This is painful but is the most important part of home treatment. After every soaking, try to push the roll a little further in.

You may take a pain reliever such as paracetamol or ibuprofen.

If you see no improvement within three days, or further symptoms develop, seek medical advice.

Medical treatment

If no acute infection is found, then the nail will be elevated and conservative treatment recommended. This consists of warm soaks, proper shoes and frequent cleaning of the nail.

Surgery

If an infection is present, or the ingrown toenail doesn’t improve, then surgical removal of the nail and drainage of any abscess will be needed. This is performed in the doctor’s surgery, by a podiatrist or in hospital. The extent of the surgical procedure will depend on the severity of the ingrown toenail and infection, any other medical problems and if this is a recurring problem.

How ingrown toenails are surgically removed:

Your tetanus status will be required and boosters given if required. With an ingrown toenail, there is a chance the open wound could develop tetanus.

The doctor will inject medicine where the toe joins with the foot. This will make the entire toe numb (local anaesthetic).

The infection will then be drained from the end of the toe.

At this point the doctor will remove a portion, or all, of the nail so that the infection can heal without the nail pushing on it and to prevent a recurrence of the problem. 

The doctor may decide to destroy some of the cells that make the nail grow back by applying a chemical to the skin under the nail or surgically removing part of the nail bed. This is so that the edge of the nail that caused the problem will not return, which is more likely with severe or recurring infections.

Antibiotics may be recommended.

The toe will then be covered with ointment and gauze.

Next steps: Follow-up

Keep the dressing that the doctor applied on for two days.

On the second day remove the dressing.

Wash with soap and water. Repeat this procedure twice a day until healed.

The doctor may want to recheck the wound in three to five days.

Take any antibiotics, if prescribed, as directed.

Keep the wound clean and dry. Follow any specific wound care instructions given by the doctor.

For the first three days keep the foot propped up above the level of the heart as much as possible. This will aid in pain control.

If the doctor prescribed pain medicine, then take it as directed. Otherwise paracetamol or ibuprofen may be used for pain control provided you have no allergies to these medications or other reasons why they shouldn’t be taken.

Outlook

The toe usually heals well after this procedure. The primary concern is whether the nail will become ingrown again, which can occur even after destruction of the nail-growing cells. If part of the toenail was removed, it will grow back within 12 months.

Prevention of ingrown toenails

The best method of prevention is careful clipping of the toenails. Toenails should be clipped straight across, taking care to keep the end longer than the skin edge. This prevents the corners digging into the skin. They should not be rounded or cut too short.

Wear well-fitting socks and shoes.

Keep the feet clean and dry.

Elderly people may need assistance because older people often have impaired vision and greater difficulty reaching their feet. Parents should check young children’s nails.

Soak the feet first to soften the nails. Always cut the nail straight across using nail clippers, and leave enough nail to cover the toe to protect it. (Do not use scissors, which are difficult to manipulate in the corners of the nail.) Smooth sharp edges with a nail file.

Women especially need to be aware that tight, pointed, high-heeled shoes and tights can cause ingrown nails by putting pressure on the toes.