When is great toe nail removal recommended?

Great Toe Nail Removal: Clinical Indications

Great toe nail removal is primarily indicated for recurrent, severe, or treatment-refractory ingrown toenails when conservative measures fail, and for dense white fungal lesions (dermatophytomas) beneath the nail that resist antifungal penetration. 1

Primary Indications

Ingrown Toenails

• Partial or complete nail removal is recommended for recurrent, severe, or treatment-refractory ingrown toenails after conservative measures have been exhausted. 1
• Conservative measures to attempt first include: correcting inappropriate footwear, managing hyperhidrosis, soaking followed by mid- to high-potency topical steroids, placing cotton or dental floss under the ingrown edge, and gutter splinting. 2
• Surgical approaches are superior to nonsurgical ones for preventing recurrence, with partial avulsion of the lateral nail edge being the most common technique. 2
• For associated granulation tissue, scoop shave removal with hyfrecation is recommended rather than complete nail removal. 1

Onychomycosis (Fungal Nail Infections)

• Mechanical nail removal is indicated when dense white lesions (dermatophytomas) develop beneath the nail, as these compact fungal masses prevent antifungal drug penetration. 1
• This presentation most commonly affects the great toenail and appears as tightly packed hyphae that resist treatment without prior removal. 1
• Important caveat: Surgical avulsion followed by topical antifungal therapy for single-nail onychomycosis showed disappointing results in randomized controlled trials and is NOT recommended as routine treatment. 1
• Debridement alone cannot be recommended as treatment for onychomycosis. 1

Special Population Considerations

Diabetic Patients

• In diabetic patients at risk of foot ulceration (IWGDF risk 1-3) with non-rigid hammertoe showing nail changes, excess callus, or pre-ulcerative lesions, consider digital flexor tendon tenotomy rather than nail removal as first-line surgical intervention. 3
• Ingrown or thickened toe nails in diabetic patients require immediate treatment by an appropriately trained healthcare professional to prevent ulceration. 3
• Assess for signs of infection or poor circulation before proceeding with any nail removal, as diabetic patients have higher risk of complications. 4
• Be vigilant for signs of infection post-procedure and consider vascular specialist consultation if signs of ischemia are present. 4

Cancer Patients with Drug-Induced Nail Toxicities

• Conservative measures should be exhausted before considering nail removal, including antiseptic soaks, topical steroids, taping, and splinting techniques. 1
• For granulation tissue management, use scoop shave removal rather than complete nail removal. 1

Common Pitfalls to Avoid

• Do not perform complete nail avulsion for fungal infections as routine treatment - the evidence shows disappointing results and it is not recommended. 1
• Do not proceed with nail removal in diabetic patients without first assessing vascular status and infection risk. 4
• Do not remove nails for drug-induced paronychia in cancer patients without first attempting conservative management. 1
• Ensure procedures are performed only by appropriately trained healthcare professionals, as improper technique can cause harm. 3

Alternative Surgical Approaches

When nail removal is indicated for ingrown toenails, several techniques exist beyond simple avulsion:

• Partial nail avulsion with matricectomy (chemical with phenol, electrosurgical, or CO2 laser) prevents recurrence more effectively than avulsion alone. 2, 5
• Soft-tissue nail-fold excision (Vandenbos procedure) with nail preservation shows excellent results with 100% success rates and high patient satisfaction in case series. 6
• The choice depends on severity, recurrence pattern, and presence of granulation tissue. 7