Ingrown nail (unguis incarnatus) is a condition characterized by the development of erythema, edema and pain at the nail edge. Although it is one of the common nail problems, its etiology is still controversial. It usually develops around the first toe nail and is frequently encountered in children, adolescents and pregnant women. In retronychia, a new form of ingrown nail identified in recent years, nail growth stops, erythema, edema and pain are localized in the proximal nail fold.
There may be cases where ingrown nail is confused with paronychia. However, while there is widespread erythema in both proximal and lateral nail folds in paronychia, this condition is usually localized in a single area in ingrown nails.
TYPES
Among the different types of ingrown nails;
Neonatal,
Infantile,
Adolescent,
Adult,
Retronichia,
There is pincer nail formation.
There are also those who think that pincer nails are a separate clinical entity with their own risk factors, apart from ingrown nails in recent years. However, there are also those who collect them under the same heading as we do here.
PATHOPHYSIOLOGY
Ingrown nail is a clinical condition that usually develops in the lateral nail fold following an irritation caused by the nail and a foreign body reaction. Here, a fracture developing at the nail edge is often present. Hypertrophy of the lateral folds at the nail edges is also a risk factor.
ETIOLOGY
Nail cutting; Cutting or breaking the nail too short or asymmetrically on one side may cause a wedge-like protruding tip to develop on the edge of the nail.
Shoe selection; Compressing the foot from the sides and keeping the nail and its edge in a very cramped environment may facilitate irritation at the nail edge.
The nail curve is larger than normal: Situations where the nail curve is excessive, such as pincer nails, may facilitate irritation of the nail edge and the skin underneath.
Obesity; The plumpness of the lateral folds facilitates irritation.
Excessive sweating; This may be a genetic feature, or it may be caused by wearing closed-toe shoes for a long time. It is also seen in people who are in bed, and excessively sweaty tissues with edema are prone to irritation and ingrown toenails.
Drugs: Some medications, such as antiviral treatments for HIV, cyclosporine, oral antifungals, retinoids, increase the risk of ingrown nails.
It has been shown to increase joint hypermobility.
In those with joint hypermobility, walking mechanics change, increasing the load on the first finger and making ingrown nails easier.
Onchomycosis; It can facilitate wedge tip development on the nail edge by increasing nail fragility.
Hallux interphalangeal joint angle: It has been shown that this angle being greater than 14.5 degrees facilitates ingrown nails.
Diabetes: The frequency of ingrown nails is higher in diabetic individuals than in non-diabetic individuals. It is thought that this condition may develop due to changes in microvascular structures.
EPIDEMIOLOGY
Ingrown nails are the most common nail disorder in the United States. 10,000 new cases are identified every year in England.
A study conducted in Korea found that the incidence of ingrown toenails was 307 per 100,000 and showed an increasing trend.
Ingrown toenails occur in men and women. While it is 3 times more common than normal, retronichia has been described more frequently in women.
PHYSICAL EXAMINATION FINDINGS
Erythema and edema are evident around the nail. However, ingrown toenails are examined in 3 stages in terms of clinical findings.
Stage 1: Mild erythema, edema and pain detected by palpation
Stage 2: Marked erythema, edema, purulent discharge
Stage 3: Erythema and edema as well as granulation tissue formation
Watering and the development of dryness are generally the findings of stage 3 ingrown toenails.
COMPLICATION
Secondary to ingrown nails. It is necessary to pay attention to the development of infection. The development of paronychia in secondary infection should warn us. Widespread and vivid red erythema, edema, and pain that are not localized only to the area where the nail is irritated indicate the need for antibiotic use. If this condition is left untreated, the infection may progress to the development of cellulitis and osteomyelitis.
On the other hand, granulation tissue is mostly composed of vasculature. It consists of different structures and therefore does not generally benefit from antibiotic treatment.
LABORATORY FINDINGS
Laboratory tests are generally not required for ingrown toenails. However, if the development of serious infection such as cellulitis and steomyelitis is suspected, white blood cell, sedimentation rate, c reactive protein and bone radiographs may be requested.
TREATMENT
General precautions: A comfortable, wide, pain-relieving, non-squeezing, foot-restoring device.
TREATMENT
General precautions: Using non-triggering shoes and/or slippers,
To prevent secondary infection, foot bath with soapy water and subsequent use of topical antibiotics,
These measures ensure that the patient remains stable until the irritation disappears and prevent the development of complications.
Apart from this, we see that many methods are used in different practices in the permanent treatment of ingrown toenails.
Until recent years, general practice included the use of conservative treatment in stage 1 ingrown toenails and surgical applications in other stages. However, this situation has still become controversial as many patients at every stage avoid consulting a physician for fear of nail extraction and the increase in conservative methods reported to be effective in other stages.
One of the most common conservative treatments is the application of cotton under the nail or similar. It is the placement of the material and the contact between the nail and the irritating tissue.
In the taping technique used for the same purpose, the granulation tissue is pulled in one direction with the help of tape, while the nail is pulled in the other direction and the contact of these two tissues is tried to be stopped.
According to another technique known as the Gutter method, the intravenous infusion tube made of silicone is cut in the middle and placed under the nail under local anesthesia. In this way, the relationship between the nail and its bed is interrupted, and the regression of this tissue is achieved by creating pressure on the granulation tissue localized in the lateral fold.
As can be seen, conservative techniques are not used only in stage 1 ingrown nails, and since the patients' wishes are in this direction, they will be used in the coming years. It is expected to increase further.
Apart from these, some other methods used include nail wire, which we also use. Gulamas are seen. The aim of these treatments is to remove the contact of the nail from the area where it is embedded and to create time for the inflammation symptoms that have developed in this area to regress.
On the other hand, the most frequently raised criticism is that conservative methods applied especially in cases of pincer nails do not prevent recurrence and that patients encounter the same discomfort after a while.
A study conducted at this point shows that if the mechanism that develops pincer nails is corrected, the results will be reduced This supports that it can be permanent. In this study, patients with pincer nails were asked to file their nails every day to reverse the nail thickening, which is the main risk factor, and no other treatment or application was applied. As a result, it was observed that the curve of the nail, which became thinner over time, continued to remain open and wide. This is a result we often see in our practice. However, in our application, we aim to thin the nail from the area where it actually starts to thicken, that is, under the nail, and we apply the application to the inside of the nail with the help of a brush.
As a result, a broken tip on the edge of the nail or the curvature of the nail thickening and deteriorating over time appear to be important mechanisms responsible for ingrown nails. Treatment aims to correct these risk factors and give the nail its previous shape, which will lead to permanent conservative results.
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