Onychocryptosis

By admin Last updated Oct 17, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Onychocryptosis

Rodney S. Gonzalez

Basics

Description

Puncturing of the periungual skin by the nail plate; this leads to a foreign body (the nail plate), inflammatory, and (possibly) infectious processes.
Alteration in the proper fit of the nail plate into the lateral or medial nail groove.
Improper fit leads to callous formation, edema, and perforation in the nail groove as a result of the rubbing of the nail plate against the nail groove.
3 stages:
- Stage 1 (mild): Erythema, slight edema, and pain when pressure is applied to the lateral nail groove
- Stage 2 (moderate): Increased stage 1 symptoms, drainage, and infection
- Stage 3 (severe): Worsening stage 1 symptoms, presence of granulation tissue, and lateral wall hypertrophy
Recurrence is not uncommon.
Synonym(s): Ingrown toenail; Unguis incarnatus; In-fleshed toenail; Embedded toenail

Epidemiology

Most commonly affects the great toe
Lateral nail edge more common than medial nail edge
26% of pathologic nail conditions
Most cases occur in males in their 2nd and 3rd decades.
Predominant gender: Male > Female (2:1 <30 yrs of age 1:1 >30 yrs of age).

Risk Factors

Shoes with tight-fitting toe box
Improperly fitting cleats
Poor stance and gait
Improper nail-trimming techniques (including tearing of nails)
Senior athletes
Onychomycosis
Diabetes
Hyperhidrosis
Obesity
Subungual neoplasms
Arthritis
Immune deficiency
Trauma, acute and repetitive
Skeletal abnormalities
Family history of in-curveted nails
Congenital and acquired nail disorders

General Prevention

Properly fitting footwear
Proper nail trimming

Etiology

Nail spicules form on the medial or lateral nail plate owing to trauma, disease processes, or improper hygiene.
Nail plate punctures the periungual skin, causing a foreign-body and inflammatory reaction.
Biologic agents (eg, bacteria and fungi) may cause an infection of the periungual skin.

Commonly Associated Conditions

Paronychia
Cellulitis
Osteomyelitis

Diagnosis

History

Ask about tight-fitting shoes: Small toe boxes predispose to onychocryptosis.
Signs of infection: Erythema, edema, and pain
Ask about recurrence and previous treatment: May affect treatment choice
History of immune deficiency or abnormal wound healing: Increased chance for severe infection and possibly require the use of antibiotics

Physical Exam

Signs and symptoms:
- Pain, swelling, and limitation of activities
- Cardinal signs of inflammation (redness, warmth, and drainage)
- In-curveted nail margin
Physical examination:
- Tenderness, erythema, edema, drainage
- Inspect for foreign bodies
- Cardinal signs of ascending infection
- Presence of excess medial or lateral wall tissue

Diagnostic Tests & Interpretation

Lab

Usually not necessary
Consider CBC, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) ± blood cultures if there is concern for a more severe infection (eg, osteomyelitis).

Imaging

Plain films and/or bone scan may be required for a severely infected toe if osteomyelitis is suspected.

Differential Diagnosis

Osteomyelitis
Cellulitis
Felon
Paronychia
Foreign body
Tumor

Treatment

Long-term treatment
Acute treatment
Analgesia:
- Depends on planned treatment option and patient discomfort level
- Recommend performing local anesthesia or a digital block with 1–2% lidocaine without epinephrine before manipulation
- Ibuprofen or acetaminophen for postoperative pain control

P.415

Immobilization:
- Patients may be full weight bearing after nonsurgical treatment.
- Partial weight bearing for 24–48 hr after surgery may be needed, but generally, weight bearing is well tolerated.
Nonsurgical treatment:
- There are no trials that compare the cost-benefit of nonsurgical versus surgical treatment options.
- Patients should be instructed in maintenance of proper foot hygiene, avoidance of shoes with a tight-fitting toe box, soaking the feet, properly trimming nails (cutting the nail straight across), and avoidance of repetitive trauma.
- Conservative treatment options:
  - Foot soaking: 10–20 min in warm, soapy water, followed by application of topical antibiotic ointment for a few days until resolution
  - Cotton wisps: Place cotton under the ingrown nail edge (also may be done with dental floss).
  - Gutter splint: Using plastic tubing (eg, IV infusion tubing) with a vertical slit and placing this over the ingrown nail edge
  - Cure rates can be as high as 75% with good patient compliance for stage 1 lesions.
  - If infection is suspected, it is important to remove the source of the infection. Antibiotics are usually not required when doing surgical treatment; when using antibiotics, they should be directed against gram-positive bacteria (eg, Staphylococcus aureus and Streptococcus spp.).

Surgery/Other Procedures

Surgery may be recommended for recurrent stage 1 lesions as below for stage 2 lesions.
- Stage 2: Remove with a wedge excision the distal outer nail edge without matricectomy.
- Stage 2 or 3: Partial removal of the medial or lateral nail with matricectomy (medial/lateral nail avulsion) ± electrosurgical or phenol cauterization
- Stage 3: In addition to the preceding, ablation of medial or lateral wall tissue to promote normalization of the medial/lateral nail fold
Major contraindications include disorders causing digital ischemia, eg, diabetes, peripheral vascular disease, and collagen diseases.
Studies shows that antibiotics before or after surgery do not affect healing time and should be withheld in most cases.
Partial nail removal with phenolization decreases the risk of recurrence; however, there may be a slight increase in postoperative infections.
Matricectomy with electrocautery and radiofrequency and carbon dioxide laser is also effective; the high cost of these procedures may be prohibitive, however.

Ongoing Care

Follow-Up Recommendations

Immune-compromised individuals with a severe infection may require hospitalization for administration of IV antibiotics.

Patient Education

Properly fitting footwear
Proper nail trimming (and foot hygiene)
Online patient handouts:
- http://familydoctor.org/online/famdocen/home/common/skin/disorders/208.html
- www.aafp.org/afp/20090215/311ph.html

Complications

Osteomyelitis
Narrowing of nail (when matrix ablation performed)
Recurrence

Additional Reading

Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician. 2009;1579:303–308.

Peggs JF. Ingrown toenails. In: Pfenninger and Fowler's procedures for primary care, 2nd ed. St. Louis: Mosby, 2003.

Bos AM, van Tilburg MW, van Sorge AA, et al. Randomized clinical trial of surgical technique and local antibiotics for ingrowing toenail. Br J Surg. 2007;94:292–296.

Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician. 2009;79:303–308.

Ikard RW. Onychocryptosis. J Am Coll Surg. 1998;187:96–102.

Mann JL, Coughlin MJ. Surgery of the foot and ankle. St. Louis: Mosby-Year Book, 1993.

Peggs JF. Ingrown toenails. In: Pfenninger and Fowler's procedures for primary care 2nd ed. St. Louis: Mosby, 2003.

Codes

ICD9

703.0 Ingrowing nail

Clinical Pearls

Antibiotics have not been shown to change the healing from ingrown toenails when using surgical treatment options.
Impact activities should be avoided until the patient is pain-free and clear of infection.
The frequencies of symptomatic nail regrowth following distal nail wedge resection, nail avulsion, and phenol and electrosurgical cauterization are distal nail wedge resection, 70%; nail avulsion, 50–80%; phenol cauterization, 4–25%; and electrosurgical cauterization, <5%.