What is an ingrowing toenail? Ingrowing/ingrown toenails (onychocryptosis) typically affect the big toenail(s); although it can affect any toe. In the lesser toes (toes 2 to 5), this is more often caused by a combination of friction and the toenail being too long - and the nail therefore curling into the flesh causing pain and potentially infection (if left untreated). However, ingrowing toenails mostly affect the big toes. This is simply due to their size - being much bigger than the lesser toes means there is more potential for the nail to be damaged, typically through friction from footwear.
What causes an ingrowing toenail? There is definitely a genetic element that can predispose a person to ingrowing toenails - this relates to the shape of the toenails and, interestingly, the distal phalanx (toe bone). I tend to see this issue in folks’ with a wide nail plate or big toenails that curl at the borders (involution) - although I have also treated patients whose toenails look like they would be classed as ingrowing; but the patient is in no pain at all; so there are clearly other factors at play. Footwear is the big one. If you look at a baby’s foot it is splayed, with plenty of room between the toes. Now look at your average adult shoe. For reasons I still do not understand (presumably aesthetics), the toebox of most footwear - even footwear that is meant to be ‘good for you’, like trainers, - has an almond-shaped toebox; so the toes are being crushed together (reducing surface area and affecting balance and the movement of the toes, in the longer term). The other thing we do is wear slip-on shoes. What you don’t realise when you are wearing a slip-on shoe is that your toes will naturally curl up to try and stabilise your foot in place, thereby applying additional pressure to the tips of your toes. Time and time again a young person will attend my clinic with what appears to be a ‘good’ shoe; we’re talking a deep, wide toebox, decent sole and a fastening (typically laces, Velcro's well and truly out isn’t it?). However, rather than bend down to untie their trainers, they simply kick them off and slide back into them at the end of the consult. Despite the fastening, this is now also classed as a slip-on shoe that is doing you no favours. The laces are there to secure your foot into the shoe. A lifetime of slip-on footwear will also cause hammer toes in the long-run - but I digress. Foot shape and walking gait can also contribute. A common example is a hyper extended big toe. Have a feel inside your shoe; can you feel a concave dip where your big toe sits in the toe box? If yes, then there’s a high possibility your toe hyperextends (flares upwards) when you walk. This will apply pressure to the nail plate, which can contribute to ingrowing toenails.Sorry to be boring, but slip-on shoes can also affect your gait (the way you walk) as you unconsciously try to keep the shoe on your foot. Resultantly, there can be backward-forward friction of the toe in the toebox, which can also contribute to ingrowing toenails - particularly if the toenails are too long. How long is too long? Your toenails should be cut so that they are in line with the tips of your toes, or very slightly (we’re talking 1 or 2mm) longer. Cutting them too short can cause ingrowing toenails as this encourages wide nail plates to grow into the flesh - and, conversely - if they are too long there is the opportunity for the nail to be ‘waggled’ in the nail bed (techical term) as the free edge (opposite to the cuticle) can catch on socks and shoes - or be repeatedly bashed into the end of a toebox. People whose jobs need them to kneel thereby putting pressure right on the very tips of the toes (particularly when teamed with steel toe-capped boots) is a common example, as are runners, and teenage boys! I’ve met a lot of sporty young chaps who are not too keen on trimming their toenails, are sweaty (causing friction), and don’t tie up their footwear properly - a perfect recipe for ingrowing toenails! Poor toenail cutting technique can also cause ingrowing toenails. This isn’t new information - everyone knows not to cut down the sides of the nails; but this doesn’t stop people having a go! The risk here is leaving a little spike of nail in the gully (sulcus) at the side of the nail plate. This little spike will then grow into the flesh, and will be more and more difficult for the sufferer to access. The rule of thumb remains to cut the nails straight across; this means to follow the natural curve of the nail without trimming down the sides. How does an infection come about? Well, the largest human organ - your skin - is absolutely covered in ‘good’ and ‘bad’ bacteria. This is absolutely normal. However, if there is a breach to the skin - caused by e.g. rubbing from footwear, scratching an itch or a nail digging into the flesh, the break in the protective skin (epithelial) barrier can allow bacteria to seep into the area, colonise (*procreate) and cause a local inflammatory cascade known as an infection. Signs & Symptoms The first sign can be a little swelling along a border of a nail, but this needn’t be painful just yet. As the nail continues to grow, it can pinch the side of the skin (causing redness) and eventually pierces the flesh, which can allow an infection to take hold (pain, redness, swelling, later pus).
What is it about infections that causes them to be painful?
Chemicals are released as part of the inflammatory process which cause a pain response. Like with all pain - to alert you to the fact that there is a problem.
So - how to fix them?
Spoiler alert: it’s not antibiotics.
Antibiotics will address the infection - but an ingrowing toenail can only be rectified by removing the piece of nail that is sticking into the flesh. You might want to have a go at this yourself, but I really wouldn’t recommend it until you’ve been shown by a professional.
An infection will persist until the spike of nail grows out (which can happen in some more mild cases) or the nail has been dealt with professionally. I do try to avoid prescribing antibiotics if possible - just one course can have a long-term deleterious affect on your gut microbiome (if you’ve ever had antibiotics, you may recall having a dicky tummy whilst taking them). This can be ameliorated somewhat by taking a prebiotic (either via a supplement, or addition of Greek yoghurt, kefir - or any other food boasting live bacteria) to your diet to counteract the antibiotics’ effects on your ‘good’ gut bacteria.
Treatment
I have often wondered why people leave it so long before seeking professional help, and the answer seems to be simply that not enough people understand what a podiatrist/chiropodist can do. Even medics.
Many patients assume they need a surgical procedure - this is not always the case; and certainly I would not perform this during an initial appointment - BUT a podiatrist/chiropodist can make the toenail/s feel significantly better (if not fully resolved) in just one appointment.
What Can I Do?
Keep the nail short to prevent repetitive trauma from footwear (which will irritate the sides of the nails, exacerbating the problem).
Gehwol Fluid. This softens the sides of the nail, reducing the friction that causes the nail to ingrow.
If there is any sign of infection, twice daily saltwater baths can really help. A saltwater bath means either a couple of tablespoons of table salt dissolved in a basin of warm water, resting the foot/feet in the basin for 15 minutes or so and then allowing the foot to air dry or dissolving two teaspoons of table salt in a cup of warm water and gently cleansing the affected toe/s with a fresh cotton wool ball or sterile gauze (taking care to use a new piece per toe affected, and not rubbing the toenail/s. Apply the soaked pad to the toe, apply a little pressure on the nail plate and sweep away from the body. Do not repeat with the same pad (this is just to avoid potential cross-contamination).
In my practice, if appropriate, I will demonstrate how to use ingrowing (fine) nail nippers to cut the nail on the oblique, (thereby encouraging the new nail to grow away from the sulcus) and use a Black’s file (very thin, pointed but not sharp) to gently check no remnants of nail have been left behind.
What Will a Podiatrist Do?
After taking a detailed medical history and performing a full foot assessment to check your protective sensation and circulation, a podiatrist will cleanse the toe with an antimicrobial (typically Hydrex or Clinisept+), gently examine the side of the ingrown nail to ease it away from the sulcus (gully at the side of the nail) and possibly allow any pus to be expressed. Fine nippers (clippers with a sharp point) are used to cut the nail on the oblique (on a wonk) in order to gently remove the symptomatic part of the nail. A scalpel may be used to gently and precisely remove any additional nail, and a Black's file used to check no remnants of nail have been left behind. The toe is cleansed again with an antimicrobial and dressed with e.g. an iodine-impregnated dressing, plus sterile gauze, a toe sock and secured with tape. This is to prevent infection, or can help to rectify a low level infection if there is one present.
Depending on the severity of the ingrown nail, this can be quite painless. A topical (a cream) or local (an injected) anaesthetic can be used if the procedure is too uncomfortable.
Surgical Management However - conservative treatment will not always work and a minor procedure to permanently remove a sliver of nail is required. This is available on the NHS - your GP (or podiatrist) can refer you directly. There is more information about the procedure here. When is surgery not an option? If you have poor circulation, uncontrolled diabetes or are otherwise immunocompromised (do not heal well and/or are prone to infections), surgery for an ingrowing toenail may not be for you. This is because of the risk of causing a wound that does not heal. Although the risks and benefits will need to be discussed - as ingrowing toenails themselves can cause non-healing wounds.
Certain drugs can also interact with the local anaesthetic - potentially causing toxicity, so pursuing a surgical procedure may be contraindicated, or could be performed in secondary care in order to have the procedure performed in a hospital setting by a Consultant Orthopaedic, Foot & Ankle or Podiatric surgeon. Blood thinners do not preclude a person from undergoing surgery, but a podiatrist will need to know an individual’s INR if they take warfarin, and/or take additional precautions (i.e. more follow-ups, more dressings or, more specifically, applying an anticoagulant dressing such as Kaltostat).
This is why a thorough medical history is taken by the podiatrist at an initial appointment in order to assess your suitability for the procedure and to discuss the patient’s full range of options (Informed Consent).
A quick note on babies toenails I am sometimes contacted by panicked new mums concerned that their baby has an ingrown toenail. A bit of a red toe on a newborn tends to be related to their naturally spoon-shaped, soft nails (these will typically flatten out and become stronger with time). Do not reach for any chemicals on a baby or toddler’s skin; gently cleanse the toe/s in salty water to prevent infection; the nail will tend to sort itself out within a week or so.
Bottom Line If you think you’ve got an ingrowing toenail, don't delay - make an appointment with a podiatrist. Simple as that!