Dermatology/ Toenail Removal

Question 1

What is an ingrown toenail?

Answer 1

A condition that arises when the lateral nail plate penetrates the lateral nail fold, entering the dermis

Question 2

What are signs and symptoms of an ingrown toenail?

Answer 2

• Pain, edema, exudates, granulation tissue

Question 3

What are risk factors for ingrown toenails?

Answer 3

• Improperly trimmed nails
• hyperhidrosis
• poorly fitting footwear
• trauma (eg, stubbing a toe)
• subungual neoplasms
• obesity

Question 4

How should nails be trimmed to prevent ingrown toenails?

Answer 4

The nail should extend beyond the nail fold before the nail is trimmed horizontally.

Question 5

How does hyperhidrosis contribute to ingrown toenails?

Answer 5

Sweat can soften nails resulting in the development of nail spicules, which can pierce the lateral skin

Question 6

How are mild ingrown toenails identified?

Answer 6

• Patients have minimal pain, little erythema, and no purulent discharge.

Question 7

What is an acceptable treatment for mild ingrown toenails?

Answer 7

Patients can attempt conservative therapy:

• soak the affected foot in warm, soapy water for 10-20 minutes daily and apply topical antibiotic ointment twice per day, or insert a cotton wisp or dental floss under the ingrown lateral nail edge

Question 8

What is the treatment of moderate or severe ingrown toenails?

Answer 8

• Lateral nail avulsion with or without matricectomy (recommended for recurrences)

Question 9

What are the various ways to perform a matricectomy?

Answer 9

1. 80%-88% phenol (contraindicated in pregnancy)
2. Carbon dioxide laser ablation
3. Electrocautery

Question 10

Should epinephrine be added to lidocaine to perform the digital nerve block?

Answer 10

No. Epinephrine causes vasoconstriction, and since digital arteries run in close proximity to digital nerves, there is a theoretical risk of causing digital ischemia.

Question 11

What instrument is used to cut the nail?

Answer 11

Typically, nail splitters are used to cut from the distal nail straight back to the proximal nail fold.

Question 12

What instrument is used to remove the lateral nail fragment?

Answer 12

Straight hemostats are used to grasp as much of the lateral nail plate as possible. Rotating the fragment toward the lateral nail fold while pulling straight out facilitates nail removal.

Question 13

What are common complications of this procedure?

Answer 13

• Postoperative patients with increasing pain, swelling, redness, or drainage should be treated for infection.
• Incomplete matricectomy can lead to regrowth of a nail spicule, which may need to be removed.