Management of Recurrent Ingrown Toenail (Onychocryptosis)
Partial permanent nail ablation is the most effective treatment for recurrent ingrown toenail affecting both sides of the toe, as planned in this case. 1
Assessment and Diagnosis
- Ingrown toenail (onychocryptosis) is characterized by the lateral edge of the nail growing into the nail fold, causing inflammation, pain, and functional limitation
- Bilateral involvement of the first toe (as in this patient) often indicates a more severe case requiring definitive intervention
- Risk factors include improper nail trimming, trauma, genetic predisposition, hyperhidrosis, and poor foot hygiene 2
Treatment Algorithm
First-line Treatment for Recurrent Bilateral Ingrown Toenail:
Partial nail avulsion with chemical matricectomy
- This approach is superior to simple avulsion alone, which has high recurrence rates
- The procedure involves removing the affected lateral portion(s) of the nail and destroying the corresponding nail matrix to prevent regrowth 2
Chemical agents for matricectomy:
- Phenol (88%): Traditional and widely used but associated with longer healing time and more drainage
- Sodium hydroxide (10%): Equally effective with faster tissue normalization (7.5 days vs 15.6 days with phenol) 3
- Trichloroacetic acid (100%): Shows 95% success rate with minimal side effects and good cosmetic results 4
Surgical technique:
- Digital block anesthesia
- Partial avulsion of the affected nail edge(s)
- Application of chosen chemical agent to the exposed nail matrix
- Thorough irrigation to neutralize the chemical
- Application of sterile dressing
Expected Outcomes and Follow-up
- Success rates of 70-95% with chemical matricectomy techniques 4, 3
- Healing typically occurs within 2-3 weeks
- Postoperative care includes:
- Regular cleaning and dressing changes
- Monitoring for signs of infection
- Elevation of the foot to reduce swelling
- Limited weight-bearing initially 1
Potential Complications
- Secondary infection (requiring oral antibiotics)
- Prolonged drainage (more common with phenol)
- Permanent nail deformity if matrix is damaged excessively
- Recurrence (5-30% depending on technique) 1, 4
Prevention of Recurrence
- Proper nail trimming technique (straight across, not curved)
- Wearing properly fitting shoes with adequate toe box
- Managing contributing conditions like hyperhidrosis
- Regular foot care and hygiene 1
Special Considerations
- For diabetic patients: More vigilant monitoring and earlier intervention due to increased infection risk
- For patients with multiple failed procedures: Consider nail tube splinting as an alternative approach 5
- For severe cases with hypertrophic nail folds: Radiofrequency excision combined with chemical matricectomy may be beneficial 6
The planned right partial permanent ablation of the right first toenail is appropriate for this 64-year-old male with bilateral ingrown toenail. This approach offers the best long-term solution for preventing recurrence while maintaining function and comfort.