Onychocryptosis, commonly known as ingrowing nails (unguis incarnatus) or ingrown toenails, is a common form of nail disease. It is a painful condition in which the nail grows or cuts into one or both sides of the nail bed. While ingrown nails can occur in both the nails of the hand and feet, they usually occur with toenails.
An ingrown toenail occurs when the nail on a toe grows into the skin. The condition can be painful and look unpleasant, but it seldom does much damage. It occurs when one of the sides of the toenail grows into and under the skin, rather than lying over the top, as is normal. The edge of the toenail disappears under the skin, making it impossible to trim. As it grows longer, the ingrown toenail cuts through the skin, when the person pushes down on the toe when walking, the toenail is forced farther into the skin, a condition that can be extremely painful.
Ingrown toenails seldom happen on their own, they form because toenails have been cut badly or a person’s shoe does not fit properly. If a toenail is cut very short, it will need to grow over a lot of skin before reaching the end of the toe. That makes it more likely that the toenail will become ingrown. The problem is made worse when the corners of the toenail are cut away. The skin along the side of the nail grows to fill the gap. When the corner of the toenail grows into that area, it will start to cut into the new skin.
Tight shoes press the toenail down into the skin and stop it from growing over the top. If the shoes are not replaced, the nail will become ingrown. Most ingrown toenails occur on the big or little toes, because they are on the edges of the foot. The big toe is the most flexible and is used most during walking, so an ingrown nail on the big toe is most painful of all.
Avoiding tight shoes and cutting toenails so they keep a straight, square shaped front edge will help prevent ingrown toenails. People who get ingrown toenails often make things worse by trying to cut the nail free. That makes it more painful and leads to infections.
Causes of ingrown toenail
An ingrown toenail usually occours due to poor foot care or unsuitable footwear. It may also result from tearing of the nail so that the edge is unprotected, and nail that are cut incorrectly. Tight shoes pressing on the growing nail and hot sweaty feet are two other factors that can cause an ingrown toenail.
- bad maintenance [like cutting the nail too short, rounded off at the tip or peeled off at the edges (versus being cut straight across)];
- 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];
- 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
- predisposition [abnormally shaped nail beds, nail deformities caused by diseases, and a genetic susceptibility to nail problems can mean a tendency to ingrowth].
Symptoms of ingrown toenail
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 pain disappears when the foot is rested, but it resumes when the person walks and the shoe presses down on the toe. Initially the area around the nail becomes slightly red and swollen, and in time it may become infected. Infection leads to increased swelling and a possible discharge of pus, so that the area becomes painful and sticky.
Staging of ingrowing toenail
For the ease of understanding, labeling and treatment planning, Heifitz classified the ingrown toenail into 3 stages:
Stage I: Pain with mild erythema and swelling of the nail fold.
Stage II: increased swelling, sero purulent discharge, and laceration of the nail-fold.
Stage III: Chronic inflammation with granulation and marked fold hypertrophy.
If left untreated
If an ingrown toenail is left untreated, there exists a high risk of dangerous infection. When the skin around the nail gets infected, it begins to swell up and put even more pressure against the nail. Ingrown nails can produce a spear shaped wedge of nail on the lateral side of the toe which will progressively become more embedded into the toe tissue as the nail grows forward. In the worst case, the swelling will begin putting sideways pressure on the nail, causing it to grow at a slant. This will cause both sides of the nail to eventually become ingrown and swollen. Eventually the swollen parts of the skin will begin to harden and fold over the nail. An untreated ingrown toenail will cause a person to walk with a limp, which over a long period of time may cause further pain and injury to the foot, leg and back owing to improper distribution of weight. Other non-direct effects of seriously ingrown nails include lack of exercise, constant and unrelenting pain and pressure which is often extreme and debilitating when weight has been on the foot for an extended period of time, the spread of infection, loss of appetite, inability to move around, and psychological effects (like anxiety, stress and feelings of despair). Amputation of the toe, foot or leg may be the final outcome if the infection is left untreated long enough for gangrene to set in as a result of a foot ulcer, most common on people with diabetes. An untreated infection may also lead to a condition known as osteomyelitis, where the infection spreads to the bone of the infected digit. Once in the bone, the infection is more difficult to remove and may require the intravenous treatment of antibiotics. One should always consult a doctor when infection is present.
The scenarios described above are “worst case”. Many ingrown toenails do not progress to an infection, and sometimes they heal themselves without intervention. However, a visit to a podiatrist is recommended if swelling is severe, if there is pus, or if the toenail remains ingrown for more than a few months.
Treatment for ingrown toenail
The initial treatment involves resting the foot; relieving any pressure from footwear; bathing regularly in hot salty water; and, if there is an infection present, using an antibiotic (where conventional medicine is concerned). These measures relieve a large proportion of cases, but in some people the condition is both chronic and recurrent; the tendency to develop the condition never completely disappears, and the site continues to become infected from time to time. Various surgical operations have been used to treat ingrown toenails, but they tend to immobilize the patient for two to three weeks. The first option is a nail wedge resection, in which the affected part of the nail is cut off under a local anesthetic; this simple procedure provides a full cure for many patients.
Another possibility is pulling of the whole nail under a local anesthetic. This allows a new nail to grown again over a period of several months. In most cases, patients find that the condition does not recur after this treatment.
In the case of an irregularly shaped nail, a plastic gutter is place along the side of the nail. This treatment allows growth to continue without the nail’s growing into and damaging the soft tissue. A local anesthetic is used for this procedure.
If all else fails, in the small minority of chronic cases, the nail and the nail forming tissue (nail bed) can be removed. This surgical procedure is usually performed under a general anesthetic. When the site heals, the nail never re-grows, and the area where the nail used to be eventually becomes covered in a tough protective skin.
Home care for Ingrowing Toenails
In mild cases, doctors recommend daily soaking of the afflicted digit in a mixture of warm water and Epsom salts and applying an over-the-counter antiseptic. This might allow the nail to grow out so it may be trimmed properly and the flesh to heal. Note that infection may be somewhat difficult to prevent in cleaning and treating ingrown nails owing to the warm, dark, and damp environment in shoes. Peroxide is immediately effective to help clean minor infections but iodine is more effective in the long term as it continues to prevent bacterial growth even after it is dry. [N.B.: Iodine should not be used on deep wounds. In such cases a physician or podiatrist should be consulted.] Also, bandages can help keep out bacteria. [N.B. One should never apply any of the new types of spray-on bandages to ingrown nails that show any discharge – preventing drainage will likely cause intense swelling and pain. Removal of spray-on bandages can be achieved with common rubbing alcohol.]
Some doctors in the very early stages of an ingrown toenail will apply silver nitrate to prevent further growth.
It is also advisable to walk around barefoot so that air has a chance to circulate. Infections often become more painful when they are not exposed to air because bacteria grow more quickly in warmer conditions e.g. when the foot is impacted tightly in a shoe.
These 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.’
The outlook for this common condition depends on the individual patient. In some cases rest and bathing produce relief within two or three days. When there is an infection, it may take several days to clear up.
It can take several months for the nail to grow back after surgery. Dressing and loose fitting, open shoes must be worn for some time. Occasionally the newly growing nail is the site of a recurrence, and then there is no solution other than to have the nail and the nail bed removed. Although this procedure provides a complete and permanent cure, the nail will never re-grow.
Homeopathy treatment of ingrown toenail
Homeopathy is one of the most popular holistic systems of medicine. The selection of remedy is based upon the theory of individualization and symptoms similarity by using holistic approach. This is the only way through which a state of complete health can be regained by removing all the sign and symptoms from which the patient is suffering. The aim of homeopathy is not only to treat ingrown toenail but to address its underlying cause and individual susceptibility. As far as therapeutic medication is concerned, several remedies are available to treat ingrowing toenail that can be selected on the basis of cause, sensations and modalities of the complaints. For individualized remedy selection and treatment, the patient should consult a qualified homeopathic doctor in person. There are following homeopathy remedies which are helpful in the treatment of ingrown toenail:
Graphites, Lachesis Mutus, Magnetis Polus Australis, Silicea, Silica Terra, Teucrium Marum Verum, Causticum Hahnemanii, Fluoricum Acidum, Natrum Muriaticum, Nitricum Acidum, Phosphoricum Acidum, Phosphorus, Staphysagria, Sulphur, Thuja Occidentalis, Magnetis Poli Ambo, Sanguinaria Canadensis
Graphites: Graphites is a mineral carbon. At is a great antipsoric homeopathic remedy. Constitutionally patient is stout, anemic, chilly with tendency to skin affection and constipation. It, therefore, resembles with Calcarea carb. Nails and skin are very unhealthy and dry, as if devoid of moisture. With this much dryness, nails become thick, they tend to deform and ingrow. With this ingrowing there is great pain, soreness and suppuration. This drug is very deep acting, so few doses are sufficient to bring the desired result.
Silicea: Silicea is directly prepared from flint. It is found in the hair, nails, skin, periosteum, nerve sheaths and in bony tissues. It is found to be indicated in a wide variety of ailments affecting various systems. The action of Silicea on skin is of paramount importance. It is very unhealthy and lacks all power of recuperation. That is why every little injury, even a scratch turns into an ugly sore. Nails of the fingers and toes become brittle and soft, they crack easily. Such soft nails when start growing inside due to wrong footwear cause inflammation and suppuration.
Besides these two there are some other remedies like Teucrium, Causticum, Thuja and Sulphur which are also found effective in cases of ingrowing toenails when prescribed on totality.
What can we do to prevent recurrence of ingrowing toenail?
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.
The following can be done in an attempt to prevent recurrence, but sometimes an ingrown nail just occurs again. Prevention can include the following:
- Wear properly fitting socks and shoes.
- If there is trauma to the toe or nail, inspect it. If it appears that the nail is damaged or this is discomfort, start soaks.
- Properly trim the nails, using appropriate toenail trimming tools. Do not cut the toenail too short, and cut the nail straight across. (If you have a sharp corner, use a nail file to round the corner)