Ingrown Toenail: Causes, Symptoms and Treatment Information for Africans

 

By Chinedu Akpa. B. Pharm. Freelance Health Writer and DLHA Volunteer. Medically reviewed by: Dr. Adegbenro Fakoya, MD, MSc., MBA, Ph.D 

Close-up of a right big toe with an ingrown toenail, showing redness, swelling, and inflammation at the nail's edge. Image credit: Campitelli, N. DPM

 

Highlights 

• Toenails are important for gripping and preventing infections

• Ingrown toenails occur when nails grow deeply into the sides of the skin of the toes.They can be very painful, but are not life-threathening.

• The condition is known globally to be a common foot dsiorder that people seek clinical care for. But there is limited data about how common it is in Africa

• It can be caused by genetics or personal behaviors, such as poor nail trimming and wearing shoes with tight toe space.

• Treatment of ingrown toenail is usually conservative, but minor surgery may be needed when conservative care fails to produce relief of symptoms.

 

Introduction

A 12-year-old Cameroonian boy was taken to the orthopedic National Social Insurance Hospital in the capital, Yaoundé. The medical history revealed no significant family, social, or past medical issues. He was sent to the hospital due to worsening condition of an ingrown toenail that he was treated for by his doctor just 36 hours prior to the referral. Apparently, he had been suffering from and dressing his ingrown nail wound of the left big toe for several months before being seen by a doctor. After a thorough evaluation, his doctor recommended that a surgical procedure be performed. [1]

This story is not uncommon, as many people suffer from ingrown nails, also known medically as Onychocryptosis. This can cause significant discomfort and complications if not treated properly. 

In this article, we will explore the causes and symptoms of this condition, providing you with the knowledge to recognize and possibly prevent it. But before doing so, let us get to know more about the structure and function of the toenail.

 

Structure and Function of the Toenail

Toenails are a plate-like structure made of skin cells; the translucent part we call the nail is technically known as the nail plate, and it is made of a hard substance called keratin. [2] 

Our toenails protect us from mechanical injuries, such as stubbing, as well as infections. It consists of various parts that work together to perform these functions. These components include the nail folds, nail bed, nail plate, and nail matrix. 

The nail folds protect the edges of our nails from injury and infections, the nail bed serves as a platform for the nail plate to attach, the nail plates are the translucent uppermost part of the nail that protects our toes from injury, and the matrix ensures that new cells are produced to promote new nail growth.

Illustration of the anatomy of a fingernail, highlighting structures such as the free nail edge, lunula, eponychium (cuticle), nail fold, and nail bed. Image: Courtesy Dr Chaigasame

 

What is an Ingrown Nail?

An ingrown nail occurs when the width of the nail does not match the surrounding skin. Specifically, a portion of the nail (known as a spicule) becomes too large and sharp. This sharp part of the nail penetrates the skin on the side of the nail (the lateral fold). When this occurs, the body produces an inflammatory response because it perceives the penetrating nail as a foreign object. This inflammation can result in a secondary infection in the affected area. [1]

Ingrown nails are most common on the big toe nail, likely due to its larger surface area, which is frequently impacted by pressure and trauma caused by shoes, particularly those that are too tight. [1]

 

How common is Ingrown Toenail in sub-Saharan Africa?

Ingrown toenail is claimed to be common in sub-Saharan Africa, but there is no comprehensive data on its occurrence across the region. [3] More than 3 million cases per year are reported in the United States though.

In one hospital based study of 138 lesions in 99 patients reported from Lagos, Nigeria, over a period of three years, the mean age of the patients was 32 years (age range of 10 – 71 years). The male: female ratio was 1.2: 1. All lesions occurred mainly on the big toe of one side only. That is to say bilateral toe involvement was rare. Patients self-identified the cause of the condition to wearing tight shoes or poor nail trimming. [3]

 

How to Stage Ingrown Toenail

Staging or classification of ingrown toenail is required because treatment is based on it. We have three stages with each having its own features. 

• Stage 1 (Mild stage): Is marked by nail-folding swelling, redness, inflammation, and pain

• Stage 2 (Moderate stage): Has features such as increased swelling, pus-filled rottenness, and infection of the nail fold

• Stage 3 (Severe stage): Show late stage redness, infection and pain, with increase in the size of the nail and new tissue formation around the wound.

It is important that the stage of the ingrown nail is identified before treatment commences. 

 

What are the Causes of Ingrown Toenail?

From the limited African data available, wearing tight fitting shoes and poorly cut nails are the two most common self-reported causes of the condition. [3]

However, podiatrist Jeremy Ousey in an interview with us, expanded the most common causes of ingrown nails in his experience in the United Kingdom as: 

• Wide nail plates

• Misshapen nails, and 

• Poorly cut nails. 

He went on to explain that wide nail plates occur when the nail has grown bigger than the toe, It then tends to push against the pulp on either side of the toe, resulting in an ingrown nail.

In the case of misshapen nails Jeremy stated that genetics, injury, or the shape of the bone beneath the toe can all be causes, which then results in ingrown nails. 

Finally, the podiatrist explained that when a sharp corner is formed as a result of nail cutting, this is pressed into when walking, causing pressure on the lateral nail fold to result in ingrown toenail. 

According to Harvard Health, wearing high heels to look stylish and classy can increase your risk of developing ingrown nails as the majority of your body weight is transferred to the foot, particularly the big toe. It warns that if this practice is repeated for years, it can lead to ingrown nails due to the pressure placed on the big toe. Other possible causes identified by this institution include fungal infection and psoriasis. [4]

 

Symptoms of Ingrown Toenail

The symptoms can be grouped into early, advanced, and chronic symptoms.

Early symptoms:

• Hardness

• Pain and tenderness

• Redness

• Swelling

Advanced symptoms:

• Increased pain 

• Infection sign

• Overgrowth of skin

Chronic symptoms: 

• Nail discoloration

• Bleeding

• Persistent swelling

• Recurrent infections

• Rottenness or Decomposition (Gangrene)

 

Complications of Ingrown Toenail

These include:

• Abscess formation

• Nail deformity

• Bone infection (Osteomyelitis)

• Spread of infection into the blood (Septicemia)

• Worsening of co-occurring diseases like diabetes.

 

Can I Prevent Ingrown Toenail?

Yes, says Dr. Gregory Alvarez, co-owner of Ankle and Foot Centers of America, a multi-location podiatric practice in Georgia, Tennessee and New Jersey in the USA. He recommends the following preventive process:

• Proper nail trimming, i.e., cutting your nails straight across
• Avoiding cutting nails too short so as to prevent the edges from growing into the surrounding skin.
• Wearing footwear with enough space to prevent toe tightening
• Maintaining proper foot hygiene - keeping your foot dry and clean to prevent any infection that may complicate ingrown toenail

Julie Schottenstein, another podiatrist in Miami, Florida, shares the same view.

 

Myths about Ingrown Toenail

It is unknown if there are myths and misconception about ingrown toenail among the populace in sub-Saharan Africa. However, Dr. Gregory Alvarez, drawing on his 34 years of experience in podiatric practice in the United States, shared some common misconceptions about the condition that he has observed among his patients.

They include the following: 

1. Only people with poor hygiene can develop this condition. Dr. Alvarez refuted this claim, stating that genetics, improper nail trimming, and tight footwear are the leading causes of ingrown nails, regardless of hygiene.

2. Cutting a "V" in the middle of a toenail is necessary to prevent ingrown nails. Again, Dr. Alvarez disagrees, saying that proper trimming of nails straight across is recommended.

3. Ingrown nails will resolve on their own. Dr Alvarez warns that this is not true as ingrown nails can lead to infections and other complications, so proper care is usually required.

 

How is Ingrown Toenail Treated?

The appropriate treatment for an ingrown nail is determined by the condition's stage and severity. There are surgical and non-surgical ways to treat ingrown toenail.

Non-surgical care is typically used for mild to moderate cases, whereas surgery is needed when the condition becomes severe. [5]

Non-surgical (conservative) care

Includes:

• Replacing or adjusting inappropriate footwear (e.g., wearing open toed shoes)

• Managing excessive sweating and fungal infections of the nails

• Soaking an affected toe in warm water followed by topical steroid application, and placing a small bundle of cotton wool under the ingrown side nail edge 

• Using over the counter pain relievers to relieve associated pain

• Gutter splintering, which seeks to guide the nail away from the surrounding skin [5]

In a separate interview, Julie Schottenstein, a podiatrist with over ten years of experience and the owner of The Schottenstein Center-Advanced Foot, Ankle and Leg Care in Miami, Florida, USA, explained how she typically treats ingrown nails in her facility. She stated that ingrown nails are typically more complicated in children than in adults because children frequently hide the condition from their parents until it becomes severe. 

She agreed that there are basically two procedures, as previously mentioned: surgical and non-surgical. 

According to Julie, the major non-surgical procedure she uses is the “Slant Back”, which is usually performed on people with a pincer nail (a pincer nail is a type of nail that grows excessively and curves inward at the sides of the toenail). In this procedure, the sides of the nail that grow inward into the skin and cause pain are clipped away. Following this procedure, the ingrown nail usually grows back, but Julie says she uses phenol solution at 80 - 90% concentration to prevent this. 

 

Surgical care

Julie identifies two types of surgical procedures for treating severe ingrown toenails as follows: 

• Partial nail avulsion and 

• Winograd procedure.

According to her, partial nail avulsion involves numbing the toenail with a local nerve pain killing agent (anesthetic) and then splitting the nail vertically at the side, scraping the nail matrix, which is the living nail cells that produce the nail, and then applying phenol solution to burn the scrapped nail matrix to prevent it from growing back. The phenol is particularly useful when there has been a recurrence. 

If phenol-based partial nail avulsion fails, Julie recommends the Winograd procedure, (Nail-wedge resection) which involves removing a portion of the ingrown toenail up to the nail matrix with a wedge of the surrounding skin. The procedure prevents an ingrown toenail from recurring and it is performed within 5 - 10 minutes after numbing the toe with nerve pain killing agent.

 

Conclusion

Understanding the causes, symptoms, and treatment options for ingrown nails are essential for effective prevention and management.

Proper nail care like cutting your toenails straight across rather than too short, and maintaing clean and dry toes are essentail preventive and conservative treatment inteventionss to adopt. 

Wearing shoes with good toe space prevents and relieves pain associated with ingrown toenails, The use of over the counter pain killers may be necessary for relieving pain.

When prevention and conservative care fails, surgical interventions may be necessary.. 

 

References

1. Noula AGM, Tochie JN, Tchuenkam LW, Abang DA, Essomba R. Surgical site infection leading to gangrene and amputation after ambulatory surgical care of an ingrown toenail: a case report. Patient Saf Surg. 2019 Dec 16;13:44. doi: 10.1186/s13037-019-0225-1. PMID: 31890029; PMCID: PMC6913014. Available from here. 

2. InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. In brief: Structure of the nails. [Updated 2021 Dec 2]. Available from here.

4. Harvard Medical Health. Foot health: What to do about an ingrown toenail. [internet, n.d]. Cited July 20, 2024. Available from here.

5. Mayeaux EJ, Carter C, Murphy TE. Ingrown Toenail Management. Am Fam Physician. 2019. Aug 1;100(3):158-164. Available from here.

 

 

Published: July 31, 2024

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