Ingrowing toenails
- Common problem in adolescents and young adults
- Usually affects the hallux but other nails may be affected
- Due to lateral edge of nail cutting and growing into adjacent soft tissue
- Bacterial or fungal infection may be superimposed
- Attempted healing may result in over granulation nail bed
- Possible aetiological factors include:
- Poorly fitting shoes
- Poor foot care
- Inappropriate nail cutting
Management
- In the early stages conservative management should be attempted
- This should include:
- Regular soaking and washing of feet
- Careful drying after washing
- Well fitting shoes
- Education into cutting nails transversely
- Possible use of pledgets of cotton wool under nail to encourage growing out
- Surgery may be required if conservative measures fail
- Nail can be removed by:
- Avulsion of the whole nail
- Wedge resection of the involved side of the nail
- Recurrence is common
- If simple avulsion fails ablation of the nail bed should be considered
- This can be achieved either chemically or surgically
- Chemical ablation can be achieved with phenol
- Surgical removal usually involves a Zadek's procedure
- Avulsion and phenolisation is more effective than surgical procedures
Subungual haematoma
- Result from blunt trauma to the hallux and nail bed
- Blood collects under the nail
- Increased pressure causes severe pain
- Nail initially appears red
- Becomes purple as blood coagulates
- Differential diagnosis includes:
- Subungual melanoma
- Glomus tumour
- Kaposi's sarcoma
- Haematoma can be evacuated by nail trephine with needle or drill
- Blood under pressure is released
- Symptoms immediately settle
Onychogryphosis
The nails in systemic disease
- Abnormalities of the nail my indicate the presence of systemic disease
- Examination of the nails is an important part of any physical examination
Clubbing
- Clubbing is the loss of the normal angle between the nail and nail bed
- Associated with:
- Bronchogenic carcinoma
- Bronchiectasis
- Congenital heart disease
- Liver cirrhosis
Koilonychia
- Thin brittle, concave nails
- Often associated with iron-deficiency anaemia
- Also seem following nail trauma and lichen planus
Splinter haemorrhages
- Small, linear steaks of blood in the long axis of the nail
- Caused by haemorrhage from vessels of the nail bed
- Due to microemboli from bacterial endocarditis
Bibliography
Alam M, Scher R K. Current topics in nail surgery. J Cutan Med Surg 1999; 3: 324-235.
Anderson J H, Greig J D, Ireland A J, Anderson J R. Randomized, prospective study of
nail bed ablation for recurrent ingrowing toenails. J R Coll Surg Ed 1990; 35: 240-242.
Clark R E, Madani S, Bettencourt M S. Nail surgery. Dermatol Clin 1998; 16: 145-164.
Fulton G J, O'Donohoe M K, Reynolds J V, Keane F B, Tanner W A. Wedge resection
alone or combine with segmental phenolization for the treatment of ingrowing toenails. Br J Surg 1994;
81: 1074-1075.
Rounding C, Hulm S. Surgical treatments for ingrowing toenails. Cochrane Database Syst
Rev 2000; 2: CD001541. |