Ingrown toenail removal

Background

• Lateral nail edge grows deep into nail wall → cycle of inflammation and hypertrophic granulation tissue can lead to abscess
• Minor cases can be treated non-surgically

Indications

• Advanced onychocryptosis (heavy granulation tissue, pain with walking)

Contraindications

• Significant granulation tissue precluding partial nail removal
• Multiple comorbidities in a patient not requiring immediate relief

Equipment needed

• Gloves
• Chlorhexidine or betadine
• Syringe with 27-ga needle
• 1% lidocaine without epinephrine or 0.5% bupivacaine
• Gauze
• Thin flat hemostat
• Straight forceps
• Iris scissors
• Aqueous phenol or silver nitrate

Procedure

• Perform Digital block using lidocaine without epinephrine or bupivacaine
• Clean area thoroughly

Partial nail removal

• If only the distal nail wall is inflamed, use iris scissors or an English nail anvil to make an oblique cut through the distal one third of the nail
• Use forceps to help remove the corner

Complete (lateral) nail removal

Removing the entire lateral portion of the nail is the more definitive treatment

• Lift the lateral quarter or third of the nail off of the nail bed with a hemostat
• Cut the nail with scissors or a nail anvil, distal to proximal, parallel to nail wall, with care not to injure the eponychium
• Grasp the nail fragment with the hemostat and pull in a twisting motion distally and toward the remaining nail until removed
• Gently debride the exposed tissue

Matricectomy

Ablating the lateral matrix can decrease recurrence

• Perform complete lateral nail removal as above
• Apply a toe tourniquet for a bloodless field
• Clean and dry base thoroughly
• Ablate nail matrix by applying 1% aqueous phenol solution or silver nitrate

Post-procedure care

• Cover with gauze, instruct to keep clean and dry, wash 2-3 times a day
• No antibiotics unless surrounding cellulitis

Complications

• Recurrence
• Infection
• Bleeding
• Retained nail fragment

See Also

• Paronychia