Section name
Section name
CRITICAL REVIEW. The conservative and surgical management of ingrowing toenails Ewan Kannegieter MSc, Surgical Trainee, Department Podiatric Surgery, Ilkeston Hospital & Tim E Kilmartin FCPodS PhD, Consultant Podiatric Surgeon, Department Podiatric Surgery, Ilkeston Hospital
I
ngrowing toenails (IGTN), otherwise known as onychocryptosis or unguis incarnatus, are a common and painful foot condition.1 Sykes2 estimated there are 10,000 new cases annually in the UK. More recently Reyzelman et al3 estimate that some 3.4 million physician visits occur each year in the US due to IGTNs. The condition most commonly affects the hallux4,5 but can also affect the lesser digits. It occurs more commonly in men than women,6 and accounts for frequent morbidity and absence from school, work and leisure time.7,8 Adolescents present most frequently with an onychocryptosis, but all age groups can be affected.1,9 Various causative factors have been proposed including congenital excess curvature of the nail, teenage hyperhidrosis, reduced ability to self care for toenails, impaired vision and natural thickening of the nail plate with age.1 Other causes include poor footwear fitting, trauma, excess weight, biomechanical issues and an overlong hallux.6,10 Patients can present with sharp pain on the affected toe, serous exudate, infection with purulence, granulation tissue, pain on walking worsened with enclosed shoes and pain from bed sheets resting on the toe.11,12 IGTNs can be a cause of chronic pathology if untreated or treated poorly and can even possibly be fatal as described by Rawes et al.13 This paper seeks to summarise recent literature on conservative and surgical management of IGTNs and to provide evidence-based recommendations for the treatment of this common condition.
LITERATURE SEARCH
AUTHOR CONTACT
Ewan Kannegieter, Department of Podiatric Surgery, Ilkeston Hospital, Heanor Road, Ilkeston, DE7 8LN Email :
[email protected]
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This article considers the many conservative and surgical management options for ingrowing toenails. It is designed to be used as a guide to inform the reader of the multiple options available for ingrowing toenail treatment and also to highlight the level of strength of evidence of these options from the available literature. This should prompt the reader to consider their current practice and review which treatments that are offered are truly effective from an evidence-based practice stand point.
In preparing this review the following databases were searched: National Center for Biotechnology Information (NCBI), Wiley International, ProQuest and the Cochrane database. The entire database up to July 2008 was included. The lead author reviewed all available abstracts and full-text articles with the emphasis on sourcing articles that attempted to measure outcomes in IGTN management. Key words identified: Ingrowing toenail, ingrown toenail, Management of… Conservative treatment of… Surgical treatment of… Treatment of…
LEVEL OF EVIDENCE GRADING
The literature reviewed in this paper, per treatment option, is graded A to D by the level of recommendation.14-16 A Requires at least one randomised
Figure 1. Toenail anatomy STAGE
SIGNS AND SYMPTOMS
TREATMENT
I
Erythema, slight oedema, and pain when pressure is applied to the nail fold
Conservative
IIa
Increased Stage I symptoms, drainage and infection, nail fold less than 3mm
Conservative and/or matricectomy with hypertrophic ungula labia fold reduction
IIb
Increased Stage I symptoms, drainage and infection, nail fold 3mm or greater
Same as Stage IIa
III
Magnified Stage II symptoms, presence of granulation tissue and nail fold hypertrophy
Matricectomy with hypertrophic ungula labia fold
Table 1. The Mozena Classification system for treatment of IGTNs
controlled trial (RCT) as part of a body of literature of overall good quality and consistency addressing the specific recommendations. B Requires the availability of wellconducted clinical studies but no RCTs on the topic of recommendation. Or systematic review of case-control or cohort studies. C Based on non-experimental descriptive studies (e.g. correlation or case control studies). D Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality. A grade I has also been used when there is insufficient evidence to make a recommendation from the available literature.17
ANATOMY (Figure 1)
The toenail is composed of the nail plate and surrounding soft tissues including the nail folds, lunula, and hyponychium. The nail plate is composed of three layers - the dorsal, intermediate and ventral sections. The nail folds occur where the peri-ungual
skin meets the nail plate, and include the proximal nail fold (eponychium), and the lateral and medial nail folds alternatively known as lateral and medial sulci. The lunula is an extension of the proximal nail fold which covers the proximal part of the nail plate. There are also three matrix elements consisting of the sterile matrix (the nail bed), the germinal matrix and the upper matrix, located on the inferior surface of the proximal nail fold. The matrix determines the shape and thickness of the nail plate and produces keratin, which forms the plate. An understanding of toenail anatomy is vital to the success of treatment offered for nail pathologies. In partial nail avulsion surgery the plate needs to be resected back inferior and proximal to the eponychium so the entire length of the nail plate is removed. The challenge of failed Zadik procedures is appreciating that nail growth occurs from not just the germinal matrix, but that the entire nail bed contributes to nail development.
CLASSIFICATIONS
Like many conditions, IGTNs have been classified into various stages. Zuber11 describes a three-stage classification December 2010 PodiatryNow
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Section name
Section name
CONSERVATIVE Advice on nail cutting Warm water soaks Cotton wool packing Debridement of nail plate Silver nitrate cautery Plastic tubing splinting Nail brace
SURGICAL Partial nail avulsion Total nail avulsion Part or total nail avulsion with: ! Liquid nitrogen ! Phenol ablation ! Sodium Hydroxide ! Laser ! Electrosurgery Partial or total excision of nail plate, nail bed & matrix Partial matricectomy with lateral fold advancement flap Symes –terminal amputation
Table 2. Management options for IGTNs
system with treatment options identified for the different stages according to severity. In stage 1 the IGTN is seen with slight swelling, pain with pressure on the nail fold and redness. Stage 2 sees a worsening of stage 1 with infection and drainage, and stage 3 shows further increased symptoms, plus hypergranulation tissue and nail fold hypertrophy. By comparison, the Mozena classification18 modifies the previous one by dividing stage II into IIa and IIb (Table 1). Mozena states that the former system makes a significant omission by not making reference to the role of the ungual labia folds. The medial sulcus of the hallux was measured in 100 patients with no history of IGTNs and concluded that a normal nail-fold depth was less than 3mm (mean 1.8mm). By comparison, 25 patients with stage IIb and stage III IGTNs had a mean nail-fold depth of 4.7mm. By recognising the depth of the nail fold, Mozena suggests that IGTNs will be more effectively treated.18 More recently Martínez-Nova et al6 have added a stage IV, a modification to the Mozena18 staging. This new stage is a result from development of stage III into a serious, chronic deformity of the nail plate involving the medial and lateral nail folds and also the distal nail fold. While the Mozena system provides the mean nail-fold depth in normal nails and stage IIb and III IGTNs this does not directly infer a properly validated and accepted classification system for IGTNs. An awareness of the increased nail-fold depth with progressing IGTN should alert the clinician to increasing severity of the IGTN but there is no established correlation to specific treatments for each stage in the classification, thereby limiting the clinical usefulness of the system.
THE MANAGEMENT OPTIONS OF IGTNS
Treatment options range from simple advice on nail cutting to amputation of the
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distal phalanx. Table 2 lists all available options and the evidence base are now considered.
REVIEW OF CONSERVATIVE TREATMENT
Conservative treatment may be considered initially before surgical treatment.1 LloydDavies & Brill19 conducted a study of the outpatient management of IGTN treatments with foot care, footwear and nail trimming advice, demonstration of cotton wool packing and silver cautery of granulation tissue. They found that after two years of conservative care 40% of patients failed to attend for further appointments, 27 % were still being actively treated and only 33% were cured.
Advice
In a qualitative study on pain, at initial redressing following toenail avulsion no patient could recall ever being given advice on preventing IGTNs.20 The Cochrane database1 states that conservative care often takes the form of basic foot care and footwear advice; this however appears to be an anecdotal statement. It would seem there is a lack of evidence to prove the benefit of advice being given to patients on prevention, rather than cure; however this may be due to the fact that when patients arrive at clinics with an IGTN it is too late to discuss prevention, rather time to proceed with treatment. The evidence for the use of advice as treatment for IGTN is insufficient and therefore supports a grade level I recommendation.
Nail brace (Orthonyxia)
A recent study by Erdogan & Erdogan21 made use of nail braces for patients with diabetes who had IGTNs. Twenty-one patients had braces applied to the nail plate, and all reported almost immediate relief from pain, redness and swelling. Patients were followed for two years and assessed for signs of recurrence. Fifteen patients (71%) had no recurrence after two years, and the remaining six (29%)
had a flare up of pain and re-used the nail brace. A prospective, non-randomised trial comparing the Emmert incisional technique against a new brace (VHOOsthold) treatment is documented by Harrer et al.8 This VHO-Osthold brace is a new method of orthonyxia composed of a three-part brace. Twenty-one patients were fitted with the brace and 20 were treated with the Emmert procedure, similar to the Winograd. After six months the recurrence rates were 19% and 15% respectively. There were key differences in results between the two methods; time off work 0 days and 14.7 days, mean cost of treatment per toe inclusive of employer personnel costs was $334.30 and $1975.20, and mean duration of treatment 77.3 days and 25.4 days respectively. There are clearly benefits to both treatments although both carry moderately high recurrence rates. The popularity of a nail brace technique has declined over the years. Harrer et al8 describe it as a long-standing technique amongst the European chiropody and podology communities referencing some 10 papers, although none of these were in the 10 years previous to their paper being written; instead ranging from 1980 to 1994. The popularity of this intervention may be related to their limited access to local anaesthesia. The nail bracing method is described as a fast, simple and inexpensive treatment option for IGTNs. These two papers8,21 are prospective clinical studies, and the results are enhanced with their long follow-ups (six months to two years) but are weakened by having neither randomisation, nor comparison to conservative options and a low number of participants. There are few studies that are contemporaneous and there is a lack of standardisation of methods. This treatment therefore is recommended as a Level B grade of evidence.
Plastic tubing splinting
A study by Nazari22 encountered 32 cases of IGTNs in a clinical trial that involved splinting of the nail plate with a flexible tube. The plastic tube was formed from the plastic cap of a small sized 29G needle from an insulin injector, used due to its flexibility and being easily obtainable. The cap was trimmed to the length of the nail plate and fitted following a local anaesthetic injection or topical anaesthesia. Patients were treated for 7 to 15 days and were reviewed at 3 and 6 months for signs of recurrence. Of these, 6.25% showed signs of recurrence at the 6month review. By comparison, 50 patients with this form of splinting were studied by Gupta et al; 39 were followed up for up to
6 months, and 20.5% showed recurrence of the IGTN.23 A modified approach was investigated by Abby et al,24 where the plastic tubing was sutured into place under a local anaesthetic on 25 patients, with 28 procedures performed. Eight (28.6%) of these had recurrence of their symptoms, yet this was deemed a relatively low rate and is advised by the study authors as the procedure of choice for IGTNs.24 Laybourn25 comments that, if a local anaesthetic and sutures were being used, then a surgical option with a higher level of success would be of greater benefit to the patient. Kim et al26 studied the splinting technique and performed an RCT of two groups assessing how long the plastic splint should be kept in situ. Group 1 (28 patients) had the splint removed after three days, and at one-year review reported a 7.1% recurrence rate. Group 2 (29 patients) had the splint removed at two weeks and reported a higher recurrence rate of 10.3%. No statistical difference was found between the two groups (p>0.05). The benefits of plastic splinting from these studies are an almost immediate reducing effect on pain and inflammation, and its ease of use. However there is no clear approach to splint duration from 3 days to 15 days or even suturing the splint in place being reported. It is not clear if this method will work on all stages of an IGTN;22,26 some authors suggest splinting is most useful in the earlier stages. Longterm success is questionable; the evidence has yet to prove that this treatment has consistent results in preventing recurrence (currently 6.25 - 28.6%) and is consistently effective for greater than six months. There is a need for larger and longer term comparative studies that add to the body of evidence to allow sufficient recommendation of its use. This treatment receives a level C recommendation in the management of IGTNs as there is no similar thread of methodology from the studies, and no long-term or prospective RCTs.
Cotton wool packing
Many authors describe cotton wool or gauze packing of the sulcus as a useful conservative treatment. Ilfeld27 advocates debridement of the advancing margin of nail and advises packing of cotton under the free edge of the nail plate to act as a buffer between the nail plate and sulcus. Henretig et al28 state that gauze packing is an effective treatment for most paediatric patients that attend with an IGTN. Reijnen29 and Connolly & Fitzgerald30 recommend the use of cotton packing with the former advising this treatment for stage 1 IGTNs. Pottie et al31 wrote an
article on practice tips – ‘inserting cotton splints to treat ingrown toenails’. They recommend that as a first-line treatment for all non-complicated IGTNs, cotton packing is the starting place and should be kept in place for 4 to 16 weeks until the painful corner of nail grows beyond the distal edge of the nail fold. The implication of this treatment is that it does not address the curvature of the nail, therefore after the packing has been removed, the nail edge will continue to press into the sulcus. These papers are mostly anecdotal, describing experience and reasonable thought of using the cotton as a buffer for stage 1 IGTNs. This treatment although logical receives a level D recommendation due to its low level of evidence. There are other conservative treatment modalities such as silver nitrate cautery32 of hypergranulation tissue, warm water soaks, antibacterial soaks33 and potassium permanganate use,34 all of which are well documented in literature for the treatment of IGTNs; however there is a dearth of evidence based on quality research for these treatments to be recommended as definitive care. These interventions receive a level D recommendation for their use in IGTN management as they are based on descriptive studies, or personal anecdotal experience of the author(s). While conservative measures have a role, it is clear their effect is short term and palliative rather than long term or curative. Where it is appropriate the patient should be offered this option, but they must also be advised of their effectiveness relative to surgical treatment.
REVIEW OF SURGICAL TREATMENT
The literature describes various techniques and variations on nail surgery; however there is no standardised method for a problem that generates thousands of outpatient appointments every year. Many questions arise - when should we offer a patient surgical treatment for an IGTN? What are the aims and outcomes of the surgery? Which method should be used? Freiberg35 and Martinez-Nova6 suggest IGTN surgery when the patient has pain and disability, or following unsuccessful conservative care. It is also suggested if the IGTN is well established, late presenting, or has problematic regrowth following previous nail surgery. Most papers agree that surgical treatment should commence if presented with a stage II or greater IGTN.10,12,18,36 The aims should include a low recurrence rate, effective pain reduction, low risk and low post-surgery morbidity for the patient. Common surgical procedures will be reviewed in the next section and recommendations
Figure 2. Partial/total nail removal without ablation
brought on their level of evidence on a procedure by procedure basis.
Partial/total nail removal without ablation (Figure 2)
Grieg et al37 undertook two studies, the first of which was a prospective randomised trial comparing total nail avulsion and nail edge avulsion both without phenolisation, and partial nail removal combined with phenol ablation. At one year postoperatively there were significant results showing recurrence rates of 73%, 73% and 9% respectively. All patients in the first study had never had surgery before for this condition. The second study by the same authors included 63 regrown nail edges from failed previous surgeries that underwent partial nail avulsion with phenol ablation and reported a 5% recurrence rate at one year follow-up. In 2007, Bos et al38 assigned 123 patients randomly into four groups; all had a partial nail avulsion, combined with either excision of the matrix or phenol ablation, with or without local application of gentamicin. One hundred and seventeen patients were available for follow-up and the authors concluded that the use of phenol over partial nail avulsion alone gave significantly improved results with regard to recurrence after one year (p
