Let’s talk about ingrown nails…
Over the last few months, I have seen so many patients who have been suffering from ingrown toenails. I don’t know why, but it’s something I am seeing across all the areas I work.
One can never believe how a small ingrown nail can cause so much pain in our daily life. It can stop you from doing the activities you love and even in bed, the duvet cover touching the toe can be excruciatingly painful.
Normally, patients get ingrown toenails on big toes but it is not unheard from in the other toes too.
There are a number of reasons that ingrown nails can occur, but if we take the events of the last couple of years into account then one of the biggest things is footwear. Being at home, wearing slippers or maybe even no shoes, and then having to move back into footwear as they return to work. The foot has been thrown into a new environment and does know what has happened to its previous found freedom for the last 2 years!
I have had grown women and men in tears with the pain caused by an ingrown toe nail. I have also been told that while they are with me, I tend to inflict a tad more pain but this quickly dissipates once I have removed the offending piece of nail spike and they feel an instant relief. Their mood changes quickly from wanting to call me every name under the sun to laughter and relief.
I have also noticed that most of patients feel that they can take care of the ingrown toenails - and I appreciate that we can all trim our nails - but, if you have nail that has a tendency to grow inwards, i.e. due to the shape of nail bed or nail, then there is a skill involved to cutting and managing them. Plus it’s much easier to cut nails when you are at the “business end”.
Anyone who has begun to age realises that for some reason the legs appear to get longer and the arms shorter, combined with a reduced flexibility.
The strange thing is when you have an ingrown toenail or any injury to the toe, is that the toe always seems to attract trauma. People stepping in it or you catching it on things, which leads to more pain and distress.
Ingrown nails are not something I would wish on an enemy, that’s for sure!
So what do we do about these pesky ingrown nails? Before I discuss that, let’s look at them in a bit more detail…
Definition:
What is an ingrown nail?
As podiatrists, we call ingrown nails “onychocryptosis”. The onycho bit means nail, the cryp bit means creeping in and the osis bit is inflammation.
A bit of nail creeping in and leading to inflammation. Simples.
They are common so don’t be embarrassed about it.
The nail begins to grow into the soft flesh on the side/corner of the nail, piercing the skin. It can be incredibly painful.
Before we discuss any further, I want to share a patient who I recently treated. He was in his mid 20s and worked in deli where he was be standing for over 12 hours a days. He worked in a kitchen environment and worn safety clogs with anti-slip resistant shoes, a bit like Crocs with socks.
A few weeks back, he reached out and said he has an ingrown toe nail. He admitted that he had tried to cut trim his nail but the pain was excruciating now. On the telephone conversation, he reported the following:
“It was painful when sleeping, especially when the duvet touched the top of his toe. Forget shoes but putting a sock had become a delicate task as it was unbearable to touch. The toe was swollen, red and hot. There was yellowish/ clear discharge plus some blood being released. There was a flesh skin growing on the side of the ingrown toe nail.”
That flesh is known as hypergranulation and is a sign of a more chronic and longstanding problem.
Anatomy of an ingrowing toenail.
Everything he described was part of the classic picture of an infected ingrown toenail.
I advised him that it would best to see him as soon as possible and I also recommended that we can ask the GP to prescribe some antibiotics once I have assessed him.
He was a little hesitant to come in. He gave a number of excuses and after a while I wised up and asked him, if he was worried I would cause him more pain. He stated that he is afraid of needles. I advised him that I would only assess him today and advise him if he did not want treatment but it is absolutely necessary that I at least look at the digit as it may be worse. I did suggest that he can use an over the counter topical anaesthetic to provide some relief and advised him to carry out some salt water foot baths, take a paracetamol two hours before coming to see me and bring in some music with him to listen to while I assessed his toe.
He reluctantly agreed to come in for an appointment later the day.
I did the usual examination in clinic, taking a history and assessing blood flow and nerves.
His history was good, but he did have one thing that can lead to an increased risk with a foot problem – diabetes. Luckily it was well controlled.
When I examined him it was pretty clear that he has an infected ingrown nail, which came with all the pain mentioned before and a decent amount of hypergranulation tissue.
I was considering that he would need a minor bit of surgery, but at this early stage assessing and making sure he was comfortable was the aim and we started the conversation about being able to take out a small bit of nail today in clinic.
I was expecting a fight on hands when I started the above conversation. I was ready to enter the battlefield, armed with all my knowledge on why he needs me to do this especially since he was diabetic, even if only diet controlled. But I think the topical local anaesthetic, the paracetamol and the salt water baths had made him more amenable or maybe I gave him the confidence he needed when I had a lengthy telephone conversation suggesting all the necessary recommendations before he came in.
He agreed and gave me consent, and while he found it painful during treatment, we moved at his pace. I kept on reminding him to focus on his breath and I am sure at time, he probably wanted me to keep quiet, but once I removed the spike and dressed it up, he was delighted and jumped up for joy. He could touch his toe and could put on the sock and shoes without any pain. I warned him there was a long road ahead for both us and things could turn nasty for any reason. Firstly he needs the digit to heal so he needs to follow certain recommendations.
I strongly recommended that he keep the affected toe dry for 48 hours.
I arranged for antibiotic cover via his GP.
He will need to continue with salt water bathing every other day
If there is a problem, to reach out to me rather than attempt anything himself.
Also advised to keep me apprised of his toe condition
Once healed, I would like to guide him with one or two appointments, on how to cut the nails in future and teach the nails to grow straight up rather than into the skin. (His nail plate was just small – some people’s nail bed is shaped differently and they may need other forms of treatment such as a minor nail surgery procedure.)
This happened a few months back and the patient was a fabulous model patient and did as I asked. I have now seen him for further follow ups and the nails are growing perfectly. He understands the need to grow the nails slightly longer and file them rather than cut if he finds them too long. When he does cut them, he cuts them just above the sulcus (side of the nail), rather than below the sulcus.
The above example was a good result, but this does not happen all the time, and sometimes we have to perform surgery.
I have a young lady who I have treated in the same way but during this time, her toe was constantly stepped on (a mother with young children who have constantly stepped on her toes) and for her, we actually had to do a nail surgery where I applied some local anaesthetic and partially remove some of her nail and apply a chemical called phenol to stop the nail from growing back.
This is a great technique, and I’ll tell you more about that in a future blog.
What causes ingrown toe nails?
Ingrown nails may develop for many reasons and maybe more common in people with sweaty feet, such as teenagers. Older people may also be at higher risk because toenails thicken with age. In my first patient, the reason he had an ingrown toenail , he had a small nail bed and nail was too large for the toe (congenital) and he liked to cut them short. Plus he worked in a deli and spent 12 hours a day standing in socks and safety clogs which meant his foot become sweaty.
Causes.
So many things can lead to an ingrown nail, but the most common are below.
Injury or trauma – whether that is a big injury or repeated small traumatic events.
Changes to nail shape such as thick or curved nails
Footwear that constricts or crowds toes
Cutting toenails too short or digging down the sides
Infection
Medical conditions such as diabetes that can change nerves and blood flow, or psoriasis that can change the quality of the nail
Teenagers as their feet tend to be sweatier which can soften the skin.
A reduced ability to care for your own nails.
Prevention.
So what do we do to stop ingrown nails? Well the best place to start is by prevention and some simple advice is below.
Trim your toenails straight across. Don't curve your nails to match the shape of the front of your toe. Your podiatrist will always trim your nails straight across and if you suffer from diabetes or any condition that causes poor blood flow or nerve damage to the feet and you struggle to trim your nails, see a podiatrist regularly to have your nails trimmed.
Keep toenails at a moderate length. Do not cut your nails below the sulcus (side of the nail ) If you trim your toenails too short, the pressure from your shoes on your toes may direct a nail to grow into the tissue.
Wear shoes that fit properly. Shoes that place too much pressure on your toes or pinch them may cause a nail to grow into surrounding tissue. If you have nerve damage to the feet, you may not be able to sense if your shoes fit too tightly.
Treatment.
If prevention doesn’t work, then treatment is needed and this is a big area.
Treatment ultimately aims to remove the bit of nail that is digging in and stop it from happening again.
In the case we saw above, this can be done in some cases without surgery and is assessed on a case by case basis.
In other cases, surgery is needed and while there is another blog coming about that, it’s a small procedure done under local anaesthetic with removal of all or part of the nail and then the application of a chemical to stop it coming back.
What next?
Well, you may be reading this and thinking “I might have an ingrown nail” and if that’s the case, get in touch. I’m always happy to have a chat to see how I can help.
And if you know of anyone struggling with a foot problem then please pass on my details.