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Nails disorders

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

Bilateral ingrowing toe nails

  • Possible aetiological factors include:
    • Poorly fitting shoes
    • Poor foot care
    • Inappropriate nail cutting


  • 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



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 is the loss of the normal angle between the nail and nail bed
  • Associated with:
    • Bronchogenic carcinoma
    • Bronchiectasis
    • Congenital heart disease
    • Liver cirrhosis


  • 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


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.



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