Better known as an ingrown toenail, onychocryptosis is the slow and progressive penetration of the nail into the fleshy margin.
It mainly affects the big toe and the symptoms are manifested by pain, pus and bleeding . The nail then appears yellow or black and the skin is inflamed. It is generally caused by unsuitable footwear, but also by trauma or incorrect nail cutting.
Treatment can be conservative in milder cases and include partial or total excision of the ingrown nail in more severe ones. The ingrown toenail is a rather frequent disorder (2.5-5% of the population), especially in the age group from 20 to 30 years.
What is the ingrown toenail
Onychocryptosis, known as ingrown toenail, is a pathological condition that generally affects the big toe (but not only) by causing a fragment of the nail to fold into the nail fold.
In other words, the edge of the nail grows inside the surrounding skin. It causes swelling and pain and can lead to an infection of the nail edge (paronychia). In severe cases (although rare), the infection can extend to the skin or bone.
It generally occurs between the ages of 20 and 30 but can strike at any age.
Prompt action is required. In fact, if neglected, it can cause very painful abscesses that require the surgical approach.
Furthermore, people with diabetes or other diseases affecting the microcirculation are at greater risk due to the reduced ability of the organism to heal wounds.
Ingrown toenail: what are the causes
The causes are different. The main one is the way in which the nail is cut : if torn, shortened too much or badly cut, it tends, in fact, to grow back laterally, piercing the skin until it causes infection .
Other factors are:
- tight toe shoes
- hallux valgus or specific shape of the big toe
- incorrect walking (for example, the toe pushing on the shoe)
- nail plates that present a predisposition to this type of pathology
- congenital deformities of the foot
- frequent foot trauma
- excessive sweating of the feet
- incorrect posture
- fungal nail infection
- poor foot hygiene.
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How does it manifest itself?
The ingrown toenail forms when a small piece or pointed corner of the lateral part of the nail (spicula) penetrates the soft tissue of the peringueal sulcus, causing pain, redness and inflammation.
A slight discomfort may be felt initially, especially when wearing shoes.
It occurs, in most cases, unilateral affecting mainly the big toe.
Although it can occur at any age, ingrown toenails are more common between the ages of 20 and 30, especially among men.
During adolescence and in any case at a young age, sweating, also favored by certain types of shoes, makes the nail plates particularly soft, favoring the formation of nail splinters.
On the other hand, in older people , difficulty in cutting nails correctly is the most frequent cause of onychocryptosis. Furthermore, the natural aging process tends to thicken the nails (particularly in people with diabetes) and make it even more difficult to cut.
Symptoms of ingrown toenails
- stinging / tingling sensation
- pain that tends to increase over time, often preventing the use of usual footwear
- red, hot, shiny and tight skin with possible purulent infection (discharge of pus).
- formation of a reddish periungual granuloma, easy to bleed and with continuous release of exudate (yellowish liquid) which tends to become more and more voluminous
- severe pain to touch
- swelling near the nail
- inability to wear any shoe
- redness of the skin surrounding the nail.
It is the underlying bacterial infection that causes the abscesses. The latter, if chronic, cause granulomas. The organism, in fact, to fight the infection tends to produce more or less extensive granulomas in the tissue surrounding the nail (periungual). This reaction is the body’s attempt to circumscribe the damaging agent (the nail plate) considered as a foreign element to defend against. A migration of leukocytes then occurs in the focus of the infection, resulting in the formation of the granuloma.
How does granuloma appear?
It is a round swelling, hard to the touch, fibrotic, bloody and purulent, with a pink-purple color.
In this phase, the symptoms are less pronounced, the infection stabilizes , but the granuloma continues to grow until it covers part of the nail plate.
Ingrown Toenail Diagnosis
The ingrown toenail is easily recognized by the doctor or podiatrist, so the diagnosis is quite simple. But in some cases it may also be necessary to perform an x-ray to exclude that at the base of the process there is a tumor of the bone or cartilage (especially in younger individuals). However, what matters is always to turn to professionals and avoid doing it yourself.
In less severe cases, the therapeutic approach is mostly conservative, where there is no pain or pus.
Therefore, it is useful to take the following precautions:
- wearing loose or open footwear
- properly cut nails (with a straight edge, avoiding rounding the contours)
- treat excessive sweating or any onychomycosis
- make regular foot baths in hot water.
Then, there are some non-surgical techniques that allow you to distance the skin margin from the edge of the nail such as “taping”:
- lifting the lamina through a gauze cone
- inserting dental floss or a plastic tube between the two surfaces.
Finally, it should be remembered that diabetic subjects develop complications more easily, as their wound healing capacity is reduced due to impaired microcirculation. Therefore, they are more exposed to the risk of infection which, in severe cases, can also involve the bone.
Redness, swelling, and pain can also suggest the presence of paronychia. This is an infection of the periungual tissue that causes redness, warmth and pain along the edge of the nail. Diagnosis is made with inspection of the affected area and treatment involves the use of antibiotics and pus drainage.
In younger individuals with recurrent recurrence of ingrown toenails, radiological examinations are recommended to rule out an underlying osteochondroma (benign bone tumor).
Finally, the absence of an ingrown toenail but with visible granulation tissue near the big toe indicates the (often overlooked) possibility of a melanoma; in this case a biopsy is required.
How to cure ingrown toenail
The choice of treatment depends on the severity of the onychocryptosis. There are three different degrees of severity of the ingrown toenail.
- I degree : inflammation of the lateral nail fold with pain and sometimes purulent exudation. In this case, it is possible to intervene in a non-invasive way, by removing the spicula and correcting the shape of the nail
- II degree : formation of granulation tissue that protrudes from the nail groove and partially covers the nail with bleeding. At this stage the pain is intense and interferes with walking.
- III degree : the granulation tissue begins to rebuild by repairing the wound caused by the perforation of the nail, forming a cushion that covers the ingrown lamina.
In the second or third degree it is important to contact a surgeon to evaluate the removal of the portion of the nail that grows abnormally and definitively solve the problem.
The surgical approach is appropriate only in the most severe or chronic cases.
The techniques are different according to the level of severity and performed under local anesthesia.
Those that eliminate excess nail are:
- partial or total avulsion (removal) of the nail
- surgical removal or destruction by laser or cryotherapy of the lateral portions of the nail matrix (the part that promotes the growth of the nail)
- elimination of the nail matrix through chemicals (the latter technique seems to be the most effective in the long term).
Instead, other techniques are based on the removal of excess skin at the level of the lateral nail fold, “freeing” the nail and reducing the conflict between the two structures.
It is a surgical technique performed for the resolutive treatment of the ingrown nail.
The relapse rate is low and the post-operative course is not very painful.
It consists in the destruction, with the use of phenol, of the lateral part of the nail matrix, so as to definitively reduce it.
It is performed with local anesthesia and lasts about 20 minutes . The post-surgery involves, for rapid healing, resting with the limb unloaded for 48 hours after surgery.
After two days, the use of footwear can be resumed, while avoiding trauma to the finger (for example for sports activities) and maceration (baths, swimming pool) for three or four weeks.
Healing is usually complete after 4 weeks. The final result, to be verified after 6-8 months, provides not only the absence of pain, but also the improvement of the aesthetic aspect.
However, this treatment is not indicated in those suffering from arterial insufficiency .
It is a conservative method which consists in the application of a flexible nickel wire hooked to the surface of the nail and fixed with a resin to recover the physiological shape of the nail .
In this case it acts on the growth of the nail, preventing the recurrence and the curvature of the lamina.
How to prevent ingrown toenail
To prevent ingrown toenails it is advisable to:
- cut straight and not curved nails
- wear comfortable shoes, not with a narrow toe and which allow good perspiration
- change socks every day
- wash your feet daily, drying them carefully after washing
- cut your nails once every 2-3 weeks (keeping the nails too short facilitates the penetration of the nail below the nail fold)
- cut cuticles and dry skin around the nail
- avoid colored socks, as dyes, thanks to sweat, can irritate the skin;
- properly cut the nails and round the edges with a file.
How to properly trim your toenails
To avoid the risk of ingrown toenails, it is good to avoid cutting the toenails too short, especially on the sides of the big toe.
Here are some tips :
- wash your feet in a small basin with warm soapy water to soften your nails
- dry your feet completely
- use scissors to cut nails or nail clippers in case of thick nails.
- use a nail file to shape them following the natural one
- do not cut the nails from the sides so as not to make them ingrown.
- The cut must be horizontal, never rounded.