ABC of General Surgery

Ingrowing Toenail

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1. What is an Ingrowing Toenail?
If the edge of the toe is painful, swollen, red and hot it is likely that the toenail is growing into the flesh on the edge and causing the inflammation. This is an ingrowing toenail.

2. What causes Ingrowing Toenail?
The commonest cause is improper cutting of the toenail leaving a sharp spike of toenail at the edge. As the nail grows, this spike pushes into the flesh like the barb of a hook and causes the pain and inflammation.

3. How do you diagnose an Ingrowing Toenail?
An examination of the toe by a chiropodist or doctor is usually all that is required to diagnose an ingrowing toenail. There is usually no need for X-rays or blood tests

4. What will happen if I have an Ingrowing Toenail and I do nothing about it?
If left alone the problem will eventually sort itself out but you will have to put up with the discomfort while it does so. Occasionally the toe becomes infected in which case the pain becomes more severe.

5. What treatment is required for an Ingrowing Toenail?
Ingrowing toenails that are not causing any symptoms do not require urgent treatment. Many patients find that, in the early stage, soaking in warm, salty water is sufficient to relieve the problem. If the pain becomes more severe, especially during walking, it is likely that more active treatment is required. This may involve trimming the nail to give more room for growth, or even a small operation where part or all of the toenail is removed.

6. What will happen if I need an operation on my Ingrowing Toenail?
If your specialist advises surgery for an ingrowing toenail it usually possible to perform the operation during a single visit and you will not need to stay overnight in hospital. The operation only requires a local anaesthetic and you will not need to be put to sleep.

7. What does the operation involve?
There are different operations that are used depending on the severity of the problem:

a) for the first-time ingrowing toenail just the edge of the nail is trimmed and sometimes a strong antiseptic solution is put onto the wound to disinfect it.

b) for a badly infected ingrowing toenail the whole nail is removed to allow the infection out and to provide pain relief. The toenail will re-grow normally over the following months.

c) for recurrent problems it is sometimes advised to have the toenail and its growing point removed so that the nail does not ever re-grow (Zadek's procedure).

8. What are the possible complications of an Ingrowing Toenail operation?
This surgery is low risk and usually provides immediate relief but a few minor complications can occasionally occur.

a) The toe has a very good blood supply and bleeding from the wound can occur and is usually caused by standing and walking too much immediately after the operation. Sit or lie with you feet up for several hours after the operation to avoid this. If the toe does bleeds despite elevation then apply some extra finger pressure on top of the dressing for 20 minutes. If this fails to stop the bleeding you will need to seek advice from the day surgery unit, your GP or the A&E department.

b) Infection of the toe does sometimes happen and is more likely if the toe was badly inflamed before the operation. If the toe becomes increasingly painful and swollen in the few days following the procedure you will need to seek advice from your GP.

9. What will happen after the operation?
After the operation the toe is dressed with a firm bandage and you are advised to sit or lie with the foot elevated for several hours. The local anaesthetic will wear off slowly over 4 hours and the toe will begin to ache. You are advised to take the prescribed pain relief tablets regularly for the next couple of days to reduce the ache. You can walk with the dressing on but are advised not to run or stand for long periods of time. After 48 hours remove the bandage and soak the dressing underneath off in a bowl of warm salty water. If the toenail has been removed completely you will need the dressing replaced and this can be done at your GP surgery by the practice nurse or by the district nurse visiting you at home. If you have had a Zadek's procedure there may be stitches in the toe that need to be removed after about 2 weeks. Keep the feet clean and change socks at least daily and use a simple dressing on the toe to prevent the socks from sticking to the wound. If you have very sweaty or "cheesy" feet you may have a fungal infection and treatment from your pharmacist or GP may be necessary to prevent problems in the future.

10. How long does it take to recover?
Most patients find that it only takes a few days to recover fully after ingrowing toenail surgery. When you return to work is dependent on the type of work that you do. Common sense says "if it hurts donít do it", and that is your best guide. If you are a driver you are safe to drive again when you can do an emergency stop without significant discomfort.

11. What can I do to speed up my recovery?
Common sense tells you that keeping the wound clean and dry and a sensible amount of exercise will allow the natural healing process do its job.

12. Where can I go for help if I think there is a problem after the operation?
Most problems that can occur are minor and can be easily remedied using the advice given in this leaflet. Before you are discharged you should be given a telephone number at the hospital that you can call to ask for advice if you are still worried. Only consider calling your GP or attending the A&E department if you are advised or you are worried and cannot contact the hospital help line or NHS Direct.

13. Will I need to come back to hospital after the operation?
Most patients do not need to be seen again in the outpatient clinic after their ingrowing toenail operation. If your specialist feels that you should be seen then an appointment should be made for you before you are discharged from hospital. If you cannot attend for any reason please inform the hospital so that your appointment can be offered to someone else.

14. Will the operation cure all the symptoms?
It is always difficult to predict the exact outcome of surgery but most patients get immediate, complete and permanent relief of their symptoms.

15. Will the Ingrowing Toenail come back?
In most patients ingrowing toenails do not come back. The best way to ensure this is correct nail cutting ... cut the toenail straight across with scissors and do not tear the toenail off leaving sharp spikes of nail along the edges!

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© S.R.Dodds 2006