What Causes an Ingrown Toenail?
Ingrown toenails in reality have only two causes. People are either born with an ingrown nail or it develops later in life due to gradual damage to the cells that grow the nail. Nails grow from an area of tissue called the nail matrix, located at the base of the nail just under the skin. Also known as the nail root, this tissue forms and pushes nails outward. Nails can grow curved inward toward the skin from this area sometimes, either due to an abnormality of the cells from birth or eventual damaging pressure from tight shoes or toe injuries. Repetitive injuries to the toe, such as heavy objects falling it, pressure from poorly fitting shoes across the top of the toe, nail fungus creating thickness and loosening, or toe bruising (common in athletes) may cause irreversible changes to the nail matrix by causing undue pressure to these fragile cells. In time, the nail may abnormally grow inward toward the skin due to these changes, rather than flat outward as in normally shaped nails. It is possible that a poor nail trimming technique may leave a spike of nail that may protrude into the skin as the nail grows outward, although this is very uncommon.
More times than not, people get ingrown nail symptoms after cutting the nail too short. Usually people nick the skin in some way, starting a skin inflammation process that eventually causes the pain by allowing the sensitive swollen skin to push against the ingrown nail side. This is really the underlying problem with ingrown nail pain. The nail itself is not the source of the pain as the skin is generally well suited to accept a curved nail next to it. The pain arises when inflammation to the skin along side the nail develops. The inflammation is painful, not the nail itself. Unfortunately, in many people, this inflammation begins to cycle regularly, with little to set it off, including tight shoes, an injury, a slightly close nail trim, et cetera. Eventually an infection can and will develop over time as bacteria becomes trapped under the swollen skin. If untreated, the chronic infection may spread along the toe skin and in very extreme cases may eventually involve the toe bone underneath, although this is very uncommon. Ingrown nail symptoms may resolve on their own, only to keep reappearing over and over again.
How Is an Ingrown Toenail Treated?
Ingrown toenails are best treated by eliminating the ingrown side of the nail altogether. Simply cutting the nail back along the corner to reduce the pressure, soaking the toe, or using an antibiotic if there is infection usually only results in temporary relief. However, for those with poor circulation, a poor immune system, or are generally in poor health, that treatment may be the best option. For all other people, permanent removal of the nail border is the best way to remove the problem. In order for an ingrown toenail to be permanently treated, the side of the nail that is pinching in needs to be trimmed off, and the nail root cells growing the nail in this spot need to be destroyed so that no further nail growth occurs there. This leaves a nail that has a straight edge that does not pinch into the skin. Without this second step of destroying the nail root cells, the ingrown side of the nail will simply grow again, causing further problems in the future.
In order to make this procedure comfortable, the toe must be numbed with a local anesthetic. This process involves injecting the toe along both sides at the base of the toe. Each side takes about 10 seconds to inject, as injecting any faster usually leads to more pain. From there onward, the toe will be numb for 4-6 hours. The skin is then cleansed with an antiseptic solution.
The toe is checked to ensure it is numb completely, and a small rubber tourniquet is applied to the toe base to decrease blood oozing that can neutralize the chemical used to destroy the nail root cells. Bleeding in this procedure is minimal to none, but still must be controlled for the best possible outcome. Following the tourniquet application, the side or sides of the nail are removed with a straight jaw nail clipper, back to the base of the nail. Several applications of an acid called phenol are then given to the cells that grow the nail at its base, to destroy them chemically. The remaining acid is rinsed with an alcohol solution, and the site is cleansed of any loose skin debris. The toe is then covered with antibiotic ointment and dressing.
Home treatment following the procedure is easy, and involves soaking the toe daily in warm soapy water and covering the site with antibiotic ointment and a band aid. Usually no restrictions in activity are needed otherwise.
Is Ingrown Toenail Surgery Painful?
Ingrown toenail procedures are by nature painless, because the toe is completely made numb by a local anesthetic before the procedure is performed. This numbing injection does sting and burn, usually no longer than 20 seconds. The toe will feel like it is filling with a hot fluid. Once the injection is complete, this sensation ends and the numbing begins. Everyone tolerates injections differently- some people barely feel them, and others have more anxiety about needles and seem to have a little more discomfort during the injection.
After the procedure is completed and the numbness wears off, some light soreness can be felt where the procedure was performed. In the first couple of days after the procedure, the toe can even throb a little. This is usually relieved with an over-the-counter anti-inflammatory medication like ibuprofen. Most people have just a little tenderness with direct pressure on the nail area for a week or two after the procedure, although some people feel no discomfort at all. For those whose ingrown toenails were very painful, there is nearly always a significant and immediate amount of relief. A very small number of people, especially those who do not follow the home care instructions, have somewhat more pain during the healing period after the procedure. This is typically due to an uncommon infection of the nail area after the procedure, or inflammation because of inadequate home care ( such as not soaking, or leaving the area to air dry instead of keeping it covered with antibiotic ointment and a band aid). Overall, though, most people successfully go through this procedure with little to no discomfort.
Scott R. Kilberg DPM 