Guidelines for Toenail Removal
Toenail removal should be performed for treatment-resistant fungal infections, ingrown toenails, or nail dystrophies, with partial nail avulsion followed by phenolization being the most effective technique for preventing recurrence in moderate to severe cases. 1
Indications for Toenail Removal
Toenail removal may be indicated in the following clinical scenarios:
- Treatment failure in onychomycosis: When antifungal therapy fails despite adequate treatment duration, nail removal in combination with further antifungal therapy should be considered 2
- Subungual dermatophytoma: Tightly packed fungal mass preventing drug penetration requires partial nail removal 2
- Ingrown toenails: Moderate to severe cases with pain, inflammation, or infection 1
- Dystrophic nails: Particularly in conditions like epidermolysis bullosa 2
- Squamous cell carcinoma in situ of the nail unit: Requires complete removal of the nail apparatus 2
Pre-Procedure Assessment
Before proceeding with toenail removal:
- Obtain mycological confirmation of infection if suspecting fungal etiology 2
- Assess for immunosuppression in cases of proximal subungual onychomycosis 2
- Evaluate vascular status, particularly in diabetic patients 1
- Consider biopsy for persistent, non-healing lesions to rule out malignancy 2
Toenail Removal Techniques
Partial Nail Avulsion
- Indication: Localized disease affecting part of the nail
- Technique: Removal of the affected portion of the nail under local anesthesia
- Advantage: Preserves healthy nail tissue 1, 3
Complete Nail Avulsion
- Indication: Extensive nail disease or as preparation for matrix destruction
- Technique: Complete removal of the nail plate under ring block anesthesia
- Note: Can achieve cure rates close to 100% when combined with antifungal therapy for onychomycosis 2
Chemical Matricectomy
- Technique: Application of phenol after nail avulsion
- Efficacy: Most effective option for preventing recurrence of ingrown toenails 1
- Advantage: Lower recurrence rates compared to surgical techniques alone 1, 4
Alternative Techniques
- Surgical matricectomy: Excision of nail matrix 4
- Electrocautery/radiofrequency ablation: Thermal destruction of matrix tissue 1
- Laser ablation: CO2 laser can be used for nail matrix destruction 2, 5
- Soft tissue procedures: Large volume removal of soft tissue surrounding the nail plate without matricectomy 6
Post-Procedure Care
- Apply topical antibiotics if indicated 1
- Regular dressing changes 1
- Elevation and limited weight-bearing initially 1
- For fungal infections, continue systemic antifungal therapy during the period of nail regrowth 2
Special Considerations
Onychomycosis
- Nail removal combined with systemic antifungal therapy can achieve cure rates close to 100% 2
- Terbinafine is superior to itraconazole for dermatophyte onychomycosis and should be first-line treatment 2
Ingrown Toenails
- Conservative measures (proper trimming, appropriate footwear) for mild cases 1
- Partial nail avulsion with phenolization for moderate to severe cases 1
- The Winograd technique, Vandenbos procedure, and Super U procedure are surgical options for recurrent cases 5
Dystrophic Nails in Epidermolysis Bullosa
- Preserve toenails where possible as they protect digit tips 2
- Apply urea-based creams daily to weekly to reduce nail thickness 2
- Chemical or laser ablation can be performed to prevent future problems 2
Nail Malignancy
- Complete removal of the nail apparatus with adequate margins 2
- Consider Mohs micrographic surgery to preserve normal tissue while ensuring adequate excision 2
Prevention of Recurrence
- Trim nails straight across 2, 1
- Wear properly fitting shoes with adequate toe box 1
- Apply emollients to cuticles and periungual tissues 1
- Manage contributing conditions like hyperhidrosis and onychomycosis 1
Pitfalls and Complications
- Secondary infection following nail removal 1
- Permanent nail deformity if matrix is damaged 1
- Recurrence of ingrown toenail if matricectomy is inadequate 1, 4
- Delayed diagnosis of malignancy if persistent lesions are not biopsied 2
By following these guidelines, clinicians can effectively manage conditions requiring toenail removal while minimizing complications and recurrence rates.