• Academy of Ambulatory Foot and Ankle Surgery. Ingrown toenails. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2003. 7 p. [30 references]

This is the current release of the guideline.

This guideline updates a previous version: Academy of Ambulatory Foot and Ankle Surgery. Ingrown toenails. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2000. 20 p.

The guideline is reviewed and updated twice a year as needed (in May and October).

Ingrown toenails

Diagnosis
Treatment

Podiatry

Podiatrists

To provide recommendations for the diagnosis and treatment of ingrown toenails

Patients with ingrown toenails

Diagnosis

1. History, including chief complaint (degree, nature, location, duration, onset, course of the pain, previous treatment) and past medical history
2. Physical examination, including peripheral vascular exam, neurological and orthopedic exam; palpation; dermatological exam; nail plate type; muscle testing
3. Diagnostic procedures, including gram stain or culture and sensitivity; x-rays; vascular studies

Treatment

1. Nonpermanent treatment, such as simple nail avulsion; incision and drainage; simple nail avulsion with debridement of the adjacent soft tissue
2. Surgical procedures, such as treatment with chemicals (e.g., phenol, sodium hydroxide); surgical removal of the matrix; laser and/or radio-wave matricectomy; bone surgery; avulsion of the offending portion of the nail and debridement of the nail if it is thick; repair of the hypertrophic ungualabia
3. Home care, such as home soaks, topical antibiotics, oral antibiotics, proper shoegear, proper trimming technique

Not stated

Searches of Electronic Databases

The guideline development process began with a thorough MEDLINE search as well as a "call for papers" from the membership of the Academy of Ambulatory Foot and Ankle Surgery at large.

Not stated

Not stated

Not applicable

Review

Not applicable

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Drafts of the guidelines were reviewed in detail by each member of the Board of Trustees.

1. Diagnosis
   1. History: This should include evaluation of the chief complaint (including the degree, nature, location, duration, onset, and course of the pain). Previous treatment and past medical history should be considered as well, especially if there is prior or family history of ingrown toenails, history of trauma, or previous history of infection.
   2. Physical examination may include:
      1. Peripheral vascular exam
      2. Neurological exam
      3. Orthopedic exam
      4. Palpate (without hurting the patient)
      5. Dermatological (i.e., infection/inflammation present)
      6. Nail plate type
      7. Muscle testing
   3. Diagnostic procedure
      1. Gram stain or culture and sensitivity may be performed in the presence of suspected infection.
      2. X-rays may be indicated if the patient has:
         1. Pain on downward or lateral pressure of the nail
         2. Clinical evidence of and/or history of chronic infections
         3. History of trauma to the toe
         4. Patient has a pincer-shaped toenail
         5. Clinical evidence of subungual exostosis
      3. Vascular studies may be indicated if:
         1. Patient has signs or symptoms of diminished circulation (i.e., lack of hair growth, shiny skin, rubor, absent or diminished pedal pulses)
         2. Patient is a diabetic
2. Types of Treatment
   1. Nonpermanent treatment--Initial treatment may consist of:
      1. A simple nail avulsion with or without antibiotic treatment
      2. Incision and drainage of the soft tissue adjacent to the nail
      3. Simple nail avulsion with debridement of the adjacent soft tissue
   2. Surgical procedure for ingrown toenails (These may be utilized alone or in combination).
      1. Treatment with chemicals such as phenol or sodium hydroxide
      2. Surgical removal of the matrix
      3. Laser and/or radio-wave matricectomy
      4. Bone surgery is indicated with the treatment of ingrown toenails when there is pain with downward pressure, when there is subungual exostosis present, or when there is osteomyelitis
      5. Treatment of the mild to moderate noninfected nail consists of avulsion of the offending portion of the nail and debridement of the nail if it is thick
      6. Repair of hypertrophic ungualabia
   3. With the above, patients may be instructed on:
      1. Home soaks
      2. Topical antibiotics
      3. Oral antibiotics
      4. Proper shoegear
      5. Proper trimming technique
3. Site of Surgery

   The surgical treatment of ingrown toenail syndrome is usually performed in the doctor's office. It may be performed in an ambulatory center or in a hospital if the patient has underlying problems or if the procedure is going to be performed in conjunction with other surgical procedures.

4. Anesthetic

   Local anesthesia is sufficient unless there are extenuating circumstances.

5. Hemostasis

   Hemostasis is desired when performing a matricectomy. This may be a tourniquet around the toe and/or anesthetic with epinephrine.

6. Surgical Preparation

   Usually aseptic scrub, prep, and draping are indicated.

7. Preoperative Lab

   Usually not necessary, but may be indicated if the doctor suspects a systemic illness. This is based on the patient's medical history and his evaluation of the current medical status of the patient.

8. Prophylactic Antibiotics

   At the discretion of the surgeon, unless the patient's medical history indicates a history of SBE, mitral valve prolapse, rheumatic fever, etc., at which time they should be given.

9. Pathological Analysis

   Pathological analysis of surgically removed tissue is recommended if suspected malignant condition exists. Mycology studies may be performed if onychomycosis is suspected.

10. Bilateral or Multiple Surgery

    May be performed at the same surgical session or in different surgical sessions as musculoskeletal surgery and/or other nail surgery. It is acceptable to operate on both feet at the same time when it is mutually agreeable to the patient and the doctor.

11. Infected Ingrown Toenail

    With this condition a nail avulsion is indicated. Anesthesia may or may not be used. In severe cases, when the patient elects to have a matricectomy in conjunction with nail avulsion, anesthesia is necessary.

12. Matricectomy in the Presence of Infection or Inflammation

    Although there are no clear cut guidelines that exist concerning the performance of a matricectomy when there is concomitant inflammation or infection, there is wide spread performance of matricectomies when inflammation/infection are present and therefore this has become an acceptable practice in podiatry.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

Treatment may relieve pain, eliminate infection, and reduce or permanently correct the deformity.

Postoperative Complications

• Toenail may grow back
• Infection
• May have to have another surgery
• Prolonged drainage
• Clot
• Nail may get deformed
• Chemical reaction
• Inclusion cyst
• Gangrene
• Loss of toe
• Loss of limb
• Phlebitis

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• Academy of Ambulatory Foot and Ankle Surgery. Ingrown toenails. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2003. 7 p. [30 references]

Not applicable: The guideline was not adapted from another source.

2000 (revised 2003 Sep)

Academy of Ambulatory Foot and Ankle Surgery - Medical Specialty Society

Academy of Ambulatory Foot and Ankle Surgery (AAFAS)

Preferred Practice Guidelines Committee

The committee consisted of five (5) members who were board certified, had a minimum of ten (10) years of clinical practice experience, and a minimum of five (5) years of teaching experience.

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Academy of Ambulatory Foot and Ankle Surgery. Ingrown toenails. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2000. 20 p.

The guideline is reviewed and updated twice a year as needed (in May and October).

None available

None available

This summary was completed by ECRI on October 12, 2000. The information was verified by the guideline developer as of December 8, 2000. This summary was updated by ECRI on December 19, 2003. The information was verified by the guideline developer on December 29, 2003.

This NGC summary is based on the original guideline, which is copyrighted by the guideline developer.