Unguis incarnatus L60.00

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 19.02.2021

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Synonym(s)

Ingrown nail; Ingrown toenail; Onychcryptosis; Onychocryptosis

Definition
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Nail ingrown into the paronychium with danger of local painful infection and consecutive formation of excessive granulation tissue.

Occurrence/Epidemiology
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The male sex is slightly more affected.

Etiopathogenesis
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Improper pedicure (round cutting of the toenails) and/or constricting footwear are frequent causes. Many patients counter the painful pressure on the lateral nail edge with a deep cutting of the nail edge. This usually leaves a small spur that progressively penetrates deeper into the lateral nail fold as the nail grows forward, causing a painful, purulent foreign body reaction. A superinfection mostly with Staph. aureus is the inevitable consequence.

Anatomical causes such as scleronychia or pincer nails or subungual exostoses.

In some patients there is a genuine tendency to the formation of an unguis incarnatus.

Furthermore, associations to diabetes mellitus, hyperhidrosis, medication (retinoids) may exist.

Manifestation
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The highest prevalence is found between 14 and 25 years of age.

Localization
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Especially toenails, especially big toenails, are affected. Fingernails are less frequently affected.

Clinical features
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Clinically, an ingrown nail without signs of inflammation is distinguished from an ingrown nail with signs of inflammation. In inflammatory Unguius incarnatus the paronychium is circumscribed reddened, swollen and clearly painful under pressure. Usually the inflammatory paronychium moves over the nail plate. Frequent formation of a highly red, weeping and purulent papule (or node) of granulation tissue. It remains to be seen to what extent bacterial nail fold angiomatosis (eruptive occurrence of exophytic granulation tissue in the nail fold of several fingers; evidence of strepto and staphylococci) should be assigned an intrinsic position (see also Granuloma pyogenicum).

Differential diagnosis
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General therapy
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  • At first try with tape bandage: With a firmly sticking plaster stiffener the inflamed nail walls are pulled away from the nail. This can prevent the foreign body irritation. Often prompt pain reduction.
  • Alternative: Tamponade of the inflamed nail fold. The padding (packing with a cut small strip of gauze soaked with an iodine ointment) can be changed daily by the patient himself.
  • Instead of a tamponade, an adapted small splint made of plastic or metal can be inserted into the lateral nail fold and left there.
  • Individually adapted nail braces (orthonyxia, see nail correction brace below) are increasingly used. The legs of the spring steel wire clasps are hung under the nail edges, connected with a loop and twisted. This lifts the nail edges. The duration of treatment is about 2-3 months.

External therapy
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Antiseptic topicals are indicated to accompany the surgical procedure or, if necessary, as a conservative therapy attempt in the case of only mild inflammation. For this purpose, cotton wool rolls with the addition of polyvidone-iodine are used. (e.g. R203, Braunovidon Lsg.). Foot baths in a lukewarm soap bath or with disinfectant additives such as quinolinol (e.g. quinosol 1:1000 or R042 ), potassium permanganate (light pink) are also used. Loose padding dressings with Polyvidon Iodine Ointment R204 or Fusidic Acid (e.g. Fucidin Ointment) are required.

Internal therapy
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In case of clear signs of inflammation with excessive granulation, additional antibiotics with flucloxacillin (e.g. Staphylex). Adults: 3-4 times/day 500 mg p.o., children > 1 year: 50-100 mg/kg bw/day i.v. or p.o. (dry juice). Alternatively Ciprofloxacin (e.g. Ciprobay): Adults: 2 times/day 0.25-0.5 g p.o., children: 10-15 mg/kg bw/day p.o.

Operative therapie
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  • The oval wedge excision of the nail edge and lifting of the nail edges has a high recurrence rate!
  • Emmert's plasty was especially recommended for recurrence, i.e. wedge surgery under Oberst's block anaesthesia. Procedure: Lateral partial resection of the nail to the periosteum. It is important to grasp the nail matrix completely from the side, otherwise a nail spur will grow back. Caution! Changed image of the distal phalanx postoperatively!
  • More recent surgical therapy approaches lead to a thinning of the nail plate and the ingrown nail edges by means of repeated abrasion, resulting in demonstrable, long-lasting therapeutic success without changing the appearance of the nail.

Notice! The simple nail extraction often leads to a relapse when the nail grows back! The recurrence can be avoided if the faulty pedicure or other promoting circumstances (tight shoes) are avoided.

Prophylaxis
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Correct nail care, i.e. do not cut the lateral nail edge round or too short.

Literature
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  1. Block SL (2014) "Nailing" the management of the ingrown great toenail. Pediatr Ann 43:434-439
  2. Bryant A, Knox A (2015) Ingrown toenails: the role of the GP. Aust Fam Physician 44:102-105
  3. Di Chiacchio N et al (2015) Best Way to Treat an Ingrown Toenail. Dermatol Clin 33:277-282
  4. Harrer J et al (2005) Treatment of ingrown toenails using a new conservative method: a prospective study comparing brace treatment with Emmert's procedure. J Am Podiatr Med Assoc 95: 542-549
  5. Keefe M et al (1987) Ingrowing fingernails: an unusual complication of acromegaly successfully treated by conservative means. Clin Exp Dermatol 12: 343-344
  6. Kreft B et al (2003) Congenital and postpartum Ungues incarnati. Dermatologist 54: 1083-1086
  7. Leahy Al et al (1990) Ingrowing toenails: improving treatment. Surgery 107: 566-567
  8. Maeda N et al (1990) Nail abrasion: a new treatment for ingrown toe-nails. J Dermatol 17: 746-749
  9. Pottie K et al (2003) Practice tips. Toenail splinting. Can Fam Physician 49: 1451-1453
  10. Rammelt S et al (2003) Treatment of ingrown toenails. What is an "Emmert plasty"? Surgeon 74: 239-43

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 19.02.2021