Onychocryptosis or more commonly referred to or known as ingrown nails can be painful and dangerous for high risk diabetic patients and patients with peripheral vascular disease. The condition can be painful for any patient and often “even the bed sheets cause the toe to hurt” The following article outlines a permanent procedure for removing ingrown toenails. Diabetic patient should first be assessed for peripheral vascular disease and glycemic control before performing the procedure. Consideration should be made to the kidney function of patients as 5-10 percent of these patients will develop post-operative infections and require systemic antibiotics. These considerations should be discussed with the patient during the pre-operative visit.
In addition care should be taken to fully evaluate the patient for any associated benign or malignant tumors involving the nail before performing a chemical matrixectomy. Although rare, any unusual “proud flesh” or unusual pigmentation of the nail bed should be biopsied before performing a chemical matrixectomy. Such benign tumors include warts(periungual and subungual), fibroma, neurofibroma, pigmented nevus, pyogenic granuloma(periungual and subungual), glomus tumor,myxoid cyst, acquired digital fibrokeratoma,keratoacanthoma, bone cysts including subungual exostosis,osteochondroma,enchondroma. Malignant tumors include bowens disease,metastatic carcinoma most commonly associated with a club appearing nail, basal cell carcinoma,malignant melanoma, and squamous cell carcinoma(the most common malignant cancer see associated with ingrown nails. If there is any clinical suspicious findings which could indicate any of the above conditions the patient should be advised of this and appropriate biopsy carried out.
There are also associated biomechanical etiologies of ingrown toenails that can be considered before performing a chemical matrixectomy. For example hallux abducto valgus deformity that is severe enough to cause the lateral border of the nail to impinge against the medial border of the 2nd toe causing the nail fold to overgrow the nail plate and thus causing the nail margin to embed within the tissue. In this situation the patient should be at least advised on the underlying etiology and at least given the option to trying a simple pad between the toes as an alternative to a chemical matrixectomy.
Performing a chemical matrixectomy
Infiltrate 3 cc of lidocaine 2% in standard hallux block. Standard prep with iodine. Introduce a freer elevator under the hyponychium and the eponychium Using a longitudinal nail splitter, create a vertical incision into the nail plate the level of the proximal nail plate. Utilize a 61 blade to finish the cut under the eponychium. Remove the offending nail border with a straight hemostat. Apply 89% phenol for 30 seconds. Repeat 2 applications of phenol. Rinse copiously with alcohol. Utilize a currette and remove excess tissue. Apply silvadene with a dry sterile compressive dressing. Follow patient as needed every 1-2 weeks.