Toenail Wedge Resection with Phenol Application Guidelines
Phenol application for 45 seconds during wedge resection is the most effective treatment for ingrown toenails, with recurrence rates as low as 1.87% at 6 months compared to 73% with simple avulsion alone. 1, 2
Procedure Technique
- Administer local anesthesia before the procedure for pain control 3
- Create a bloodless field using a tourniquet at the base of the toe 2
- Perform a partial nail avulsion (wedge resection) of the affected portion of the nail 2, 4
- Apply 80% fresh phenol to the exposed nail matrix for 45 seconds to chemically ablate the nail-forming cells 2, 1
- Clean the area thoroughly after phenol application to remove excess chemical 2
Indications
- Ingrown toenails (onychocryptosis) with pain, inflammation, or infection 2, 5
- Recurrent ingrown toenails after previous simple avulsion 2
- Cases with hypertrophy of nail folds causing nail ingrowth 5
Advantages of Phenol Application
- Low recurrence rate of 2.2-4.5% compared to 73% with simple avulsion alone 2, 4
- Minimal postoperative discomfort and quick return to normal activities 5
- Simple, inexpensive procedure that can be performed in general practice settings 2
- Lower rates of post-operative infection and spike formation compared to wedge resection alone 4
Post-Procedure Management
- Daily antiseptic soaks with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily 6
- Apply mid to high-potency topical steroid ointment to nail folds twice daily to reduce inflammation 6
- If infection is suspected, obtain cultures and initiate appropriate antibiotics with coverage against Staphylococcus aureus 3, 6
- Regular nail trimming is necessary until the nail plate grows reattached 3
- Monitor for signs of infection including increased pain, redness, swelling, or purulent drainage 3, 6
Management of Complications
- For granulation tissue formation, options include scoop shave removal with hyfrecation or silver nitrate application 3, 6
- For recurrence after phenolization (rare at 1.87-4.5%), repeat phenol cauterization is typically successful 2, 1
- For persistent pain or drainage beyond 2-4 weeks, reassessment and possibly additional intervention may be required 6
Prevention of Recurrence
- Ensure proper nail trimming technique - cut straight across, not too short 6
- Wear comfortable well-fitting shoes and cotton socks 6
- Avoid cutting cuticles or manipulating the nail folds 6
- Apply topical emollients to cuticles and periungual tissues daily 6
Special Considerations
- The medial nail fold has a higher recurrence rate than the lateral nail fold after phenolization 1
- Patients with previous failed surgeries have higher recurrence rates (two-thirds of recurrences occur in patients with previous surgical failures) 2
- Total nail ablation is rarely necessary; partial phenolization is usually sufficient 7
- Early intervention is recommended to prevent complications and improve outcomes 7