Ingrown Toenail

1 What is Ingrown Toenail?

It is also known as Onychocryptosis. When a toenail is ingrown, it is curved and grows into the skin, usually at the nail borders (the sides of the nail). This “digging in” of the nail irritates the skin, often creating pain, redness, swelling, and warmth in the toe.

If an ingrown nail causes a break in the skin, bacteria may enter and cause an infection in the area, which is often marked by drainage and a foul odor. However, even if the toe isn’t painful, red, swollen, or warm, a nail that curves downward into the skin can progress to an infection.

If left untreated, an ingrown toenail can progress to an infection or even an abscess that could require surgical treatment.

Ingrown toenails are common in adults and adolescents but less common in children and infants. They are more common in men than in women. Young adults in their 20's or 30's are most at risk.

Any nail can become ingrown, but the condition is usually found in the big toe.

2 Symptoms

The most common signs and symptoms of ingrown toenail are pain, redness, and swelling at the margins of a toenail.

An ingrown toenail is a common disorder that most often affects the outer edges of the nail of the big toe. However, the nail on any toe can become ingrown.

  • Early in the course of an ingrown toenail, the end of the toe becomes reddened and painful with mild swelling. There is no pus or drainage. It may feel warm to the touch, but you will not have a fever.
  • Later, extra skin and tissue will grow around the sharp point of the nail. A yellowish drainage may begin. This is the body's response to the trauma of a nail irritating the skin and is not necessarily an infection.
  • Sometimes an infection develops. In this case, the swelling will become worse, and there may be white- or yellow-colored drainage (pus) from the area. A lighter-colored area of the skin may be surrounded by red skin. A fever may develop, although this is unusual.

3 Causes

Causes of ingrown toenails include:

  • Heredity. In many people, the tendency for ingrown toenails is inherited.
  • Trauma. Sometimes an ingrown toenail is the result of trauma, such as stubbing your toe, having an object fall on your toe, or engaging in activities that involve repeated pressure on the toes, such as kicking or running.
  • Improper trimming. The most common cause of ingrown toenails is cutting your nails too short. This encourages the skin next to the nail to fold over the nail.
  • Improperly sized footwear. Ingrown toenails can result from wearing socks and shoes that are tight or short.
  • Nail Conditions. Ingrown toenails can be caused by nail problems, such as fungal infections or losing a nail due to trauma.

4 Making a Diagnosis

Your doctor will do a physical exam to diagnose an ingrown townail.

An exam of the foot will show the following:

  • Skin along the edge of the nail appears to be growing over the nail, or the nail seems to be growing underneath the skin.
  • Skin is swollen, firm, red, or tender to touch. There may be a small amount of pus.

Tests or x-rays are usually not needed.

5 Treatment

Ingrown toenails are usually treated by a GP or a person qualified to diagnose and treat foot disorders (a chiropodist). A newer term for chiropodist is podiatrist. In some cases, surgery is helpful.

If caught early:

If the ingrowing part of the nail is small, it may be prevented from becoming worse, and sometimes cured, by the following. This treatment may be given by a podiatrist or GP, or you may be shown how to do it yourself:

  • Soak the toe in water for 10 minutes to soften the folds of skin around the affected nail.
  • Then, using a cotton wool bud, push the skin fold over the ingrown nail down and away from the nail. Do this starting at the root of the nail and move the cotton wool bud towards the end of the nail.
  • Repeat each day for a few weeks, allowing the nail to grow.
  • As the end of the nail grows forward, push a tiny piece of cotton wool or dental floss under it to help the nail grow over the skin and not grow into it. Change the cotton wool or dental floss each time you soak your foot.
  • Do not cut the nail but allow it to grow forward until it is clear of the end of the toe. Then cut it straight across and not rounded off at the end.

There are variations on this method - the principle is to keep the skin from growing over the edge of the nail.

If the nail fold becomes infected:

Symptoms of infection are increasing pain, swelling and redness near the ingrowing nail, and yellow or green fluid (pus) near the nail or under the nearby skin. If the infection is getting worse, you may have a throbbing pain, redness spreading over the toe, or a high temperature (fever).

Antibiotics may be needed to treat infection. It can also help to soak your feet in warm salty water, then carefully dry and rest your feet.

When should I see a doctor?

See a doctor if:

  • You have persistent and troublesome symptoms from the ingrowing nail.
  • You have symptoms of infection (as above). If you also have diabetes or a poor immune system, see a doctor urgently, as infections will need treating quickly.
  • You have a condition affecting the nerves or feeling (sensation) in your foot. For example, if you have loss of feeling due to diabetes (diabetic neuropathy) affecting the feet. This is because a loss of sensation can make you unaware of problems in the foot, such as a deep infection. So, you will need careful assessment and monitoring. You may be referred to a foot clinic or podiatrist.

For persistent ingrowing toenails:

It may be necessary to remove part of the nail. The usual procedure is as follows:

  • The toe is made numb and painless by injecting local anaesthetic into the base of the toe.
  • The toenail is then cut with scissors longways a few millimetres in from the offending edge.
  • It is cut right up to the base of the toenail and the offending edge can then be pulled out.
  • A small amount of acid (called phenol) is often put on the exposed part of the nail bed. This helps to stop the edge of nail regrowing and causing another ingrown nail.
  • The nail is then dressed.

Once the anaesthetic wears off the toe may be sore so you may need mild painkillers such as paracetamol for a day or so. You will probably have to wear a bandage for about two weeks. During this time you will not be able to have a bath or go swimming. You also will not be able to do any strenuous exercise, such as running. After the operation, the nail will regrow but will be narrower than before.

6 Prevention

There are several methods to prevent ingrown toenail, which include:

  • Cut your nails straight across; do not cut them too short or too low at the sides.The corner of the nail should be visible above the skin. (Tip: it is easier to cut nails after a bath or shower, when they are soft.)
  • Keep your feet clean and dry. Let air get to your toes when possible.
  • Avoid tight shoes and use cotton socks rather than synthetic.
  • If you have diabetes, you should take extra care when cutting your nails:
  • Cut the nail straight across or follow the shape of the end of the toe, but be very careful not to cut too low at the sides as above.
  • Gently file any sharp edges with a nail file.
  • If you have any loss of feeling in your feet, you should visit a chiropodist (podiatrist) to have your nails trimmed, rather than doing it yourself.
  • If you can't see your feet or nails very well, you should visit a chiropodist (podiatrist) to have your nails trimmed, rather than doing it yourself.

7 Lifestyle and Coping

Ingrown toenail can be avoided by following simple lifestyle changes, which include attention to detail and good hygiene.

Preventing Ingrown Toenail Pain:

Some of us can admit that maintaining the appearance of our feet isn’t very high on our list of priorities. But, those of us that have experienced the inconvenient pain from an ingrown toenail beg to differ. An ingrown nail on your big toe can alter numerous daily activities that your life revolves around. Whether it’s playing sports or standing for long periods of time, our feet guide the quality of our lives.

Here are some tips on maintaining your nails in general.

  • Routinely inspect your feet. Foot problems in general can become “a pain” and even turn into chronic (6 months or longer) conditions that lead to other diseases. If you have diabetes, consider visiting with a podiatrist on a regular basis.
  • Make sure your toes and nails are clean by removing dirt and lint from underneath your toenails.
  • When clipping your nails, trim them straight across instead of the common “arched cut.” If you receive routine foot pampering, make sure you relay this preference.
  • Although you shouldn’t trim your nails to match the shape of your toe, it’s important that you maintain a healthy nail length. The tips of your toes should align with the edges of your toenails. Long nails place pressure on the base of your toenail while trimming them short can actually encourage them to grow into your toe.
  • Those with blood flow conditions should always have their toenails trimmed by a foot and ankle specialist (podiatrist).

Below are some additional tips that prevent ingrown toenail pain.

  • Buy shoes that actually fit your feet, especially if you have lower extremity nerve damage. Often times, we purchase shoes with fashion in mind – but if you’re looking to avoid a painful experience, ensure the shoe fits before you wear it.
  • When participating in specific activities, purchase corresponding footwear. Don’t attempt to run a marathon in flats, play basketball in boots, or hike in loafers. All of these situations alter the way you’re able to move – therefore altering the intense pressure on your feet. Remember, pressure alters the growth pattern of your toenails.
  • When immersing yourself in circumstances that involve risk, make sure you’re wearing protective footwear. Those of you on construction sites without steel-toe boots should re-evaluate the situation. Damage to your foot or toes can lead to chronic conditions that affect nail growth as well.

8 Risks and Complications

There are several complications associated with ingrown toenail.

A persisting ingrown toenail can have serious consequences. A localized infection of the nail border (paronychia) can progress to a deeper soft-tissue infection (cellulitis), which can in turn progress to a bone infection (osteomyelitis).

Complications can include scarring of the surrounding skin and nail borders as well as thickened, deformed (onychodystrophy) fungal toenails (onychomycosis).