One of the most common complaints a podiatrist sees is ingrown toenails. A patient will often present to the office with a several day history of pain in one or both corners of any one of the nails, but usually the great toe. An injury or a bad day at the pedicure or nail salon can start a process that ends with a trip to the podiatrist. In more severe cases, a patient will wait up to a month (or more) and at this point, the entire toe can be swollen to twice its normal size, be red in color, draining pus, and barely be able to get his or her shoe on. Patients do go to the ER for these conditions, but more often than not this can be treated safely, quickly and effectively in the office setting.
In the milder cases, the painful toe is cleaned with rubbing alcohol to mildly disinfect the area, and without any anesthesia, the offending corner of the nail can simply and painlessly be trimmed back until the patient is comfortable. Usually there is no bleeding involved, and the patient can return to normal activities without any restrictions. As we move up on the scale of severity, local anesthesia is used to make the patient more comfortable, and it allows the doctor to be much more aggressive in resecting the problematic nail. With a small tourniquet placed around the base of the toe, a larger portion of nail (an entire border) can be removed, or both borders can be removed at the same time when necessary. If there are signs of infection, the wound is cultured to identify which bacteria are causing the problem, and the patient can be placed on an oral antibiotic regimen tailored to the causative organism. Staph. aureus is a common infectious agent with infected ingrown nails, but a culture can determine if just one or more types of bacteria are present. With diabetics, it is especially important to get a good culture because the ramifications of not adequately defeating the infection can be severe.
Occasionally, there is cellulitis surrounding the entire toenail, and in this case the entire toenail plate can safely be removed. A new nail will usually grow back completely in less than a year. A culture can be taken if indicated, and/or the nail plate can be sent to a lab for examination if a skin cancer is suspected. Often a mycotic (fungal infection) nail can be identified in a lab, and the report can indicate one or more fungus or yeast present, which can be helpful in selecting future treatments.
If there is no or minimal infection present, a chemical called phenol can be placed in the matrix or root area of the toenail, and after this has healed up, a new nail usually does not grow back. This type of procedure takes a little longer to heal (about a month rather than just a week or so), but the odds of another painful or infected nail are greatly decreased. If you have had severely painful nail episodes in your life and are looking for a way to minimize the chance of it happening again, give me a call and we can find a time to review your medical history and see which option is best for you.
Richard C. Bennett, D.P.M.