What is the proper technique for removing an ingrown toenail in a patient who continues to complain about it?

Surgical Treatment for Persistent Ingrown Toenail

For a patient with persistent ingrown toenail complaints, perform partial nail avulsion of the affected lateral edge combined with chemical matricectomy using phenol—this is the definitive treatment with the lowest recurrence rate and best outcomes 1.

Recommended Surgical Technique

The standard approach involves:

• Partial nail extraction from the ingrown lateral edge (not complete nail removal)
• Chemical matricectomy of the corresponding matrix portion using phenol
• This combination prevents regrowth of the problematic nail edge while preserving nail aesthetics

Phenol Application Protocol

Based on current UK practice standards 2:

• Apply phenol 3 times to the exposed matrix
• Total application time of 3 minutes (1 minute per application is most common)
• This destroys the matrix cells responsible for lateral nail growth
• Phenol is universally preferred (97.2% of practitioners) over other chemical agents

Staging-Based Decision Algorithm

The Dutch guideline 1 provides clear staging criteria:

Stage I (mild inflammation, no granulation tissue):

• Conservative treatment may be attempted first
• If this fails, proceed to surgical treatment

Stage II-III (granulation tissue, infection, severe inflammation):

• Proceed directly to partial nail avulsion with phenol matricectomy
• Do not waste time with conservative measures

Specific Surgical Steps

A standardized 6-step approach 3 ensures consistency:

1. Administer local anesthesia (digital block)
2. Apply tourniquet to create bloodless field
3. Excise the ingrown lateral nail edge (approximately 2-4mm width)
4. Remove all granulation tissue and diseased soft tissue
5. Apply phenol to exposed matrix (3 applications × 1 minute each)
6. Neutralize with alcohol and dress appropriately

Alternative Technique for Recurrent Cases

If standard phenol matricectomy fails (recurrence rate 1.7-7.6% 4, 5), consider:

• Lateral fold and partial nail bed excision 5
• Creates a 2mm permanent space between tissue and nail
• Success rate of 92.4% even in recurrent cases
• Minimal matricectomy preserves cosmetic appearance

Expected Outcomes

Set realistic patient expectations:

• Return to daily activities: 3 days 4
• Return to work: 5 days average 6
• Complete healing: 10 days 4
• Recurrence rate: <2-7% depending on technique 4, 6, 5
• Operation time: 3 minutes for the excision itself 4

Critical Pitfalls to Avoid

Do NOT perform complete nail avulsion alone—this has unacceptably high recurrence rates without matricectomy. The guideline evidence 1 explicitly recommends against nail removal without matrix destruction.

Do NOT delay surgery for infected cases—treat active infection with antibiotics first, then operate once inflammation improves 6. Operating on acutely infected tissue increases complications.

Do NOT use inadequate phenol application—underapplication (fewer than 3 applications or insufficient time) leads to incomplete matrix destruction and recurrence 2.

Special Populations

The technique remains the same for:

• Recurrent ingrown toenails (no need to modify approach) 1
• Patients with expected wound healing problems (diabetics, immunosuppressed) 1
• All age groups, though younger males (age 22) have slightly higher recurrence rates 4

Complications Are Rare

Expected complications 4, 6:

• Hematoma: <1%
• Infection: <1%
• No neurovascular complications reported with proper technique
• Deep infection is extremely rare with appropriate sterile technique