Dermatology Online Journal

Autologous "foreign body" as a sequel of improper cutting of an ingrowing toe nail?
Berthold Jessberger MD¹, Johannnes Ring MD PhD^1,2, Matthias Möhrenschlager MD³
Dermatology Online Journal 15 (7): 12

1. Department of Dermatology and Allergy Biederstein, Technical University of Munich, Munich, Germany
2. Division Environmental Dermatology and Allergology GSF/TUM, Department of Dermatology and Allergy Biederstein, Technical University of Munich, Munich, Germany
3. Department of Dermatology, Hochgebirgsklinik, Davos, Switzerland. matthias.moehrenschlager@hgk.ch

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Abstract

We report on a 63-year-old male who suffered from an ingrown toenail affecting the left first digit for several years. Medical history revealed that repeated vigorous nail plate trimming by the patient relieve the red, painful swelling of his great toe. Furthermore, Emmert onychoplasty as well as non-invasive procedures did not achieve improvement. A thorough surgical exploration of the affected area detected a nail spicule in the deeper paronychium. This was likely caused by improper cutting of the nail plate. Removal of the fragment in combination with partial nail plate excision, followed by phenol cauterization of the matrix resulted in full recovery.

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Introduction

An ingrown toenail (unguis incarnatus) is a common, often painful condition, characterized by inflammation of the lateral nail fold that is caused by the intrusion of the adjacent margin of the nail plate [1]. We report on a patient suffering from unguis incarnatus of the left great toe for several years, with accompanying paronychia, granulation tissue formation, as well as recurrent infection.

63-year-old male complained of a red, painful, warm swelling of the left great toe for several years that caused substantial discomfort during periods of activity (e.g., walking) as well as at rest. He mentioned a habit of repeated, sometimes vigorous, trimming of the distal lateral nail plate, which showed excess curvature, to reduce discomfort from nail pressure on the underlying soft tissue. In an attempt to relieve the condition, the patient underwent Emmert onychoplasty as well as several non-invasive procedures (e.g., chiropody, taping, metal brace) without success in the past.

Clinical examination revealed an enlarged, erythematous, left big toe with granulation tissue in the lateral nail fold. Pressure upon the sharply demarcated warm lesion was painful without purulent discharge. Furthermore, palpation localized a circumscribed mass on the left side of the distal phalanx.

Cultures performed of lesional swabs grew Staphylococcus aureus, which prompted systemic antibiotic treatment with oral cefuroxime (500 mg bid).

Figure 1
Figure 1. MRI of left great toe (sagittal T2-weighted spin echo image): diffuse inflammation of soft tissue with pronounced visualization of contrast media is noted. There are signs of osseous involvement at the distal phalanx

Magnetic resonance imaging (MRI) with contrast media of the first digit of the left foot revealed a diffuse inflammation of the soft tissue with pronounced enhancement of contrast media and a 3 mm fluid collection, resembling abscess formation. At the distal phalanx signs of osseous involvement were detected (Fig. 1).

In addition to ongoing systemic antibiotic therapy a surgical procedure was performed after anesthetic block (Oberst method) of first left digit. The lateral portion of the nailplate was elevated from the nail bed with a Freer septum elevator. The remaining nail plate was separated by use of scissors without affecting the proximal nail fold and the skin adjacent to the matrix zone. A forceps was used to harvest the separated lateral nail plate (Figs. 2 & 3), whereas the visible granulation tissue of the lateral nail fold was removed by curettage.

Figure 2	Figure 3
Figure 2. Surgically removed ingrown toe nail (bottom) and horny spicule (top) in 1:1 projection on the patient's first digit. Figure 3. Surgically removed ingrown toe nail (bottom) and horny spicule (top). Note spicule surface showing changes similar to a foreign body reaction.

Additional thorough exploration of the operation site, including manual pressure on the distal portion of the phalanx (where a mass had been localized by palpation pre-operatively) led to the emergence of a solid, horny object, which could be easily harvested from the surrounding tissue. Inspection of the object confirmed the presence of a triangular part of the nail plate (Figs. 2 & 3), most probably created by a nail cutting procedure in the past.

After phenol cauterization of the lateral matrix zone, iodine ointment was applied topically and the toe was covered with a pressure bandage. The first change of the wound dressing was made at the third post-operative day. The wound healed without any complication, resulting in a full recovery.

We report the case of a nail spicule embedded in the lateral nail fold, which was most probably produced by improper cutting of an ingrown toenail. The spicule acted as a persistent stimulus for inflammation of the surrounding tissue.

The reasons for the development of ingrown toenails is still a matter of dispute, but improper cutting and pressure from unsatisfactory footwear are probably the major factors in the elderly [1]. Other causes include hereditary, or constitutional inequality between the width of the nail plate and that of the nail bed or overcurvature of the nail plate [1]. Sweating and pointed and / or high-heeled shoes seem to be only minor contributing factors [1]. Most often, the great toenail is affected.

Improper cutting of the ingrown toenail may produce a spicule of nail, which can induce damage to the lateral nail fold when not completely removed [1]. With time, the spicule becomes embedded in the surrounding soft tissue where it may act like a "foreign body."

In cases without inflammation, treatment of an ingrown toenail may consist in separating the nail's edge from the adjacent tissue by application of a cotton wool pad. Other methods of separation (e.g., by fixation of a bracelet or a splint) may also be useful [2].

If conservative measures fail and the patient experiences excessive inflammatory granulation tissue formation and repeated episodes of infection, a more definitive approach is recommended. In the past, total ablation of the matrix and nail bed was recommended, which seems obsolete today due to superior techniques [3].

Emmert onychoplasty consists of a wedge-shaped resection of the lateral part of the nail plate, the nail bed, and the matrix zone [4]. Nevertheless, a substantial proportion of patients encounter a recurrence of the ingrown toenail.

In partial nail plate avulsion, the ingrowing part of the nail is freed from the proximal nail fold, nail bed, and matrix with a Freer septum elevator. The ingrowing strip of nail is cut longitudinally and removed. Afterwards, cauterization of the lateral matrix is performed by application of cotton wool soaked with liquefied phenol (96%) for 1 minute. Provisions must be made to protect surrounding tissue (generally by use of petrolatum jelly) and to neutralize the phenol with 70 percent alcohol afterwards [4].

Interestingly, topical applied phenol works also as anesthetic and antimicrobial agent, resulting in reduction of postprocedural pain and microbiological colonization, respectively. In regard to recurrences, Grieg et al., found a relapse rate of 9 percent for this procedure [5].

In the case reported here, it is hard to understand why the previous Emmert onychoplasty failed to detect the nail spicule responsible for the ongoing inflammation. Even the MRI provided only indirect evidence for an embedded spicule.

Our case highlights the need for thorough exploration during surgery of an ingrown toenail. The possibility of a hidden nail plate fragment must be considered, especially in cases with persisting clinical signs of inflammation.

References

1. Baran R, Haneke E, Richert B. Pincer nails: definition and surgical treatment. Dermatol Surg. 2001 Mar;27(3):261-6. [PubMed]

2. Haneke E. Segmentale Matrixverschmälerung zur Behandlung des eingewachsenen Zehennagels. Dt Med Wschr. 1984 Sep;109(38):1451-3. [PubMed]

3. Haneke E. Surgical treatment of ingrown toenails. Cutis. 1986 Apr;37(4):251-6. [PubMed]

4. Haneke E, Baran R. Nail surgery. Clin Dermatol. 1992 Jul-Sep;10(3):327-33. [PubMed]

5. Grieg JD, Anderson JH, Ireland AJ, Anderson JR. The surgical treatment of ingrowing toe nails. J Bone Joint Surg Br. 1991 Jan;73(1):131-3. [PubMed]

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