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 When nail goes against the toe

Dr Najjia Ashraf
Ingrown toenails occur when a piece of the nail breaks the skin - An ingrown toenail is where the edge, or corner, of the toenail grows into the adjacent skin (the skin next to the edge of the nail) and pierces the skin, causing the toe to become red, swollen and tender (inflamed).
Ingrown toenails are very common in the large toes. When a toenail is ingrown, the nail is curved downward 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 your toe isn't painful, red, swollen, or warm, a nail that curves downward into the skin can progress to an infection.
Causes Include
1. Bad maintenance (like cutting the nail too short, rounded off at the tip or peeled off at the edges (versus being cut straight across)
2. Ill-fitting shoes [those that are too narrow or too short can cause bunching of the toes in the developmental stages of the foot (frequently in those under 21), causing the nail to curl and dig into the skin];
3. Trauma to the nail plate or toe [which can occur by stubbing the toenail, dropping things on the toe and 'going through the end of your shoes' during sports, can cause the flesh to become injured and the nail to grow irregularly and press into the flesh]; and
4. Predisposition [abnormally shaped nail beds, nail deformities caused by diseases, and genetic susceptibility to nail problems can mean a tendency to ingrowth].
Symptoms of an ingrown nail include pain along the margins of the nail (caused by hypergranulation that occurs around the aforementioned region), worsening of pain when wearing shoes or other tight articles, and sensitivity to pressure of any kind, even the weight of bed sheets or a duvet. Bumping of an affected toe with objects can produce sharp, even excruciating, pain as the tissue is punctured further by the ingrown nail. By the very nature of the condition, ingrown nails become easily infected unless special care is taken to treat the condition early on and keep the area as clean as possible. Signs of infection include redness and swelling of the area around the nail, drainage of pus and watery discharge tinged with blood. The main symptom is swelling at the base of the nail on whichever side (if not both sides) the ingrowing nail is forming.
The most common place for ingrown nails is in the big toe, but ingrowth can occur on any nail. Ingrown nails can be avoided by cutting nails straight across; nails should not be cut along a curve, nor should they be cut too short. In both cases, the important thing to avoid is cutting the nail shorter than the flesh around it. Footwear which is too small, either in size or width, or those with too shallow a 'toe box' will exacerbate any underlying problem with a toenail.
It may not be so critical that the nails be cut perfectly 'straight across' as this may imply that they be squared at the corners. Leaving sharp square corners may be uncomfortable and cause snagging on socks. The important thing to keep in mind is that you want to be able to 'SEE' the corners. You should be able to see the side edge of the nail as it meets the front edge of the nail. This way, you can be sure there is no 'splinter' veering off to the side and growing into your toe. Careful filing of the corner is reasonable. For some people the nail curves down on the sides, in this case it would be difficult to ever see the side edge of the nail plate and this cutting method does not apply. Some nails require cutting of the corners far back to remove the edge that digs into the flesh, this may be done as a partial wedge resection at your podiatrist's office.
Ingrown toe nails can be caused by injury, commonly blunt trauma where the flesh is pressed against the nail causing a small cut that swells. Also, injury to the nail can cause it to grow abnormally, making it thicker or wider than normal or even bulged or crooked. Stubbing the toenail, dropping things on the toe and 'going through the end of your shoes' in sports are common injuries to the digits. Injuries to the toes can be prevented by wearing properly fitting shoes, especially when working or playing.
One myth is that a V should be cut in the end of the ingrown nail; this myth is untrue. The reasoning of the myth is that if one cuts a V in the nail, the edge of the nail will grow together as the nail grows out. This does not happen - the shape of the nail is determined by the growing area at the base of the toe and not by the end of the nail. A notch does no good, and may do harm if it is cut too deeply.
Some doctors will apply silver nitrate to granulation tissue (overgrowth of irritated tissue at the side of the nail. This may look like reddish cauliflower, bleeds easily). This may shrink and or remove this sensitive overgrown tissue at the side of the nail.
The home remedies are, in serious cases, ineffective: when the flesh is far too swollen and infected these procedures will not work. Thus, these more severe cases, such as when the area around the nail becomes infected or the nail will not grow back properly, must be treated by a professional and the patient should avoid repeated attempts at this type of 'bathroom surgery.'
Physician care
The foot and ankle surgeon will examine your toe and select the treatment best suited for you. Treatment may include:
  •  Oral antibiotics. If an infection is present, an oral antibiotic may be prescribed.
  •  Surgery. A simple procedure, often performed in the office, is commonly needed to ease the pain and remove the offending nail. Surgery may involve numbing the toe and removing a corner of the nail, a larger portion of the nail, or the entire nail.
  •  Permanent removal. Various techniques may be used to destroy or remove the nail root. This treatment prevents the recurrence of an ingrown toenail. Your foot and ankle surgeon will determine the most appropriate procedure for you.
Following nail surgery, a light bandage will be applied. Most people experience very little pain after surgery and may resume normal activity the next day. If your foot and ankle surgeon has prescribed an oral antibiotic, be sure to take all the medication, even if your symptoms have improved.
Preventing Ingrown Toenails
Many cases of ingrown toenails may be prevented by following these two important tips:
  •  Trim your nails properly. Cut your toenails in a fairly straight line, and don't cut them too short. You should be able to get your fingernail under the sides and end of the nail.
  •  Avoid poorly-fitting shoes. Don't wear shoes that are short or tight in the toe box. Also avoid shoes that are loose, because they too cause pressure on the toes, especially when you run or walk briskly.
The Truths About Home Treatment
Myth: Cutting a notch (a "V") in the nail will reduce the tendency for the nail to curve downward.
Truth: Cutting a "V" does not affect the growth of the toenail. New nail growth will continue to curve downward.
Myth: Repeated trimming of the nail borders is a good way to treat ingrown toenails.
Truth: Repeated nail trimming fails to correct future nail growth and can make the condition worse.
Myth: Cotton placed under the nail will relieve the pain.
Truth: Cotton placed under the nail can be harmful. It can easily harbor bacteria and encourage infection.
Myth: You can buy effective ingrown toenail treatments at the drug store.
Truth: Over-the-counter topical medications may mask the pain, but they fail to address the underlying problem. Consultant Dermatologist and Cosmetologist at National Medical Centre Kalapul