Kembara Xtra - Medicine - Ingrown Toenail In an ingrown toenail, the lateral nail fold is invaded by the distal edge of the nail plate, resulting in discomfort, inflammation, and occasionally bacterial or fungal infection: Erythema, edema, and discomfort to palpation of the lateral nail fold are symptoms of stage 1 (inflammation), while increasing pain, erythema, and edema as well as drainage (purulent or serous) are symptoms of stage 2 (abscess). - Stage 3 (granulation): Prolonged inflammation causes more erythema, edema, and pain; frequently, granulation tissue forms over the nail plate and there is substantial nail fold hypertrophy. May occur again Onychocryptosis and unguis incarnatus are similar terms. Epidemiology The great toenail is most frequently affected. The medial edge of the nail is less frequently impacted than the lateral edge. Most prevalent in men between the ages of 14 and 25. Rare, but occurs more frequently in elderly women than in senior men.More prevalent in people with lesser means 24.5 per 1,000 people overall; 50 per 1,000 people aged 65 or older are affected. Pathophysiology and Etiology The nail plate pierces the nail fold, resulting in an allergic response (inflammation). Infection and abscess formation may result from bacteria or fungus entering through the nail fold, which can also cause granulation tissue and hypertrophy of the nail fold. Risk Elements Genetic Elements - Medial rotation of the toe - Wider nail folds There were many additional theories put forth but none were supported, including the following: - Thickened and deformed nails (onychogryphosis) - Onychomycosis, a fungal illness - Hyperhidrosis - Improper lateral nail plate cutting - Ill-fitting shoes - Injury to the nail or nail fold - Diseases that increase the risk of developing pedal edema (such as thyroid dysfunction, diabetes, obesity, heart failure, and renal disease) Preventative measures include proper shoe fit and nail care. Patients typically present with pain, redness, and swelling in the toe along one or both sides of the nail, with or without drainage as infection and/or inflammation progress. Clinical Assessment Erythema and edema, drainage (serous or purulent), granulation tissue, and lateral nail fold enlargement are all symptoms of nail fold discomfort. Differential diagnosis: Felon (pulp abscess on plantar portion of toe) and cellulitis. The excessive thickening and hardening of the nail, or onychogryphosis. Nail detachment from the nail bed is known as onycholysis. Onychomycosis, a nail-fungal infection. Osteomyelitis and paronychia, an infection or swelling around the nail fold, Subungual osteochondroma, a benign bone tumor, and subungual exostosis, a bony projection from the distal phalanx Laboratory Results Initial examinations (lab, imaging) typically not necessary. If osteomyelitis is suspected, an MRI, x-ray, or bone scan may be appropriate. If subungual exostosis or osteochondroma are detected, an x-ray should be taken. Management The vast majority of cases benefit from conservative treatment. Soak in warm, soapy water or Epsom salts for ten to twenty minutes three times daily until symptoms go away. Stubbornly tuck a cotton swab or piece of dental floss under the ingrown nail. Until the nail extends past the fold, the patient can keep replacing the insert. Until the nail grows past the fold, use tape to draw the lateral nail fold away from the nail plate. Stage 2 ingrown nails frequently react to the above-mentioned conservative treatment, particularly cotton wool, or a tryout of cryotherapy. Medication: Topical antibiotics can be given after soaking; NSAIDs are typically effective for analgesia; neither oral nor topical antibiotics are helpful as a surgical therapy adjunct. Surgical therapies Compared to nonsurgical therapies, surgical procedures are more effective at preventing recurrence. Nail avulsion methods outperform nail fold debulking methods (not included in this area). - Phenol nail matrix ablation with partial nail avulsion. Obtain surgical consent after outlining the advantages, disadvantages, and available options. Use a digital wing or ring block to achieve local anesthetic. To help with hemostasis, you can think about applying a tourniquet around the base of your toe (use caution if you have diabetes or peripheral vascular disease). Use a periosteal (Freer) elevator or hemostat to raise the ingrown portion of the nail from the nail bed. Cut the nail longitudinally, beginning at the distal edge and moving toward the matrix, with scissors or a nail splitter a few millimeters from the ingrown border. Using longitudinal traction and, if necessary, rotation to the lateral nail fold, grasp the avulsed fragment with a hemostat down to the cuticle and gently draw it out. When hemostasis is achieved, release the tourniquet. Dip a urethral swab in an 80–88% phenol solution (using phenol during pregnancy is not advised). Apply the phenol to the nail matrix beneath the proximal nail fold three times for 30 seconds each time. To remove phenol, clean the area with 70% isopropyl (rubbing) alcohol. A flexible gutter splint is one nonsurgical method that can be used to treat stage 2 or stage 3 ingrown nails. Flexible gutter splint, type J Cut a sterile plastic tube, such as IV tubing, that is 1 to 2 cm long and 2 to 3 mm in diameter (or use the cap from a 29-gauge needle instead). Cut a lengthwise split in the tube, then lop off the end at an angle. Utilize a digital wing or ring block to administer local anesthetic. Using a hemostat, separate the ingrown nail's edge from the nail fold. Slide the tube down the nail's ingrown edge, angled end first. Consider using tape, a single stitch through the nail plate, or self-curing formable acrylic resin (used for dentures and sculptured nails) to secure the tube in place. As soon as the nail has grown past the nail fold, keep the tube in place. Permanent destruction of the germinal matrix can be employed to avoid recurrence. Patients with severe ingrown toenail or recurrence should have bilateral partial matricectomy. Phenol nail bed ablation is probably more successful at preventing recurrence than nail avulsion alone. – Nail bed ablation alternatives besides: Electrocautery with a specific flattened tip coated with Teflon on one side to protect the proximal nail fold, Cryotherapy, Sodium hydroxide (NaOH), and Laser carbon dioxide Removal of the nail matrix surgically Follow-up: Apply sterile petroleum jelly or antibiotic ointment to the area and cover with sterile gauze and tube gauze. The following should be included in the postop instructions: - Elevate the foot and rest it for 12 to 24 hours. - Use NSAIDs to relieve pain. – Following surgery, for one to two weeks, you should at least daily change your dressing and wash with soap and water. - A sterile exudate is normal for 2 to 6 weeks. – If there is no matrix ablation, it may take 6 to 12 months for avulsed nails to fully recover. – Call for swelling, redness, or increasing pain. Patients who are treated conservatively should be checked in at the clinic every 7 to 10 days until a noticeable improvement is seen. - The average time to resume normal activities is 2 weeks. Patient Education Do not round the corners while trimming nails; instead, cut them straight across and not too short.Put on a pair of comfy, well-fitting shoes. Cellulitis following surgery is a rare complication. Damage to the nail bed, periosteum, or fascia from excessively severe matrix ablation, and distal toe ischemia from extended tourniquet use during surgery (rare). Nail matrix degradation that results in nail plate deformation (Rare) Osteomyelitis. Permanent nail narrowing (in the event that partial matrix ablation is done). Recurrence (40–80% with avulsion alone, 0.6–14% with matrix ablation, 6–13% with gutter splint), persistent postoperative wound drainage, particularly with severe phenolization of neighboring tissues.
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