Today, we’re introducing a new series Ask A Podiatrist! — featuring Elizabeth E. Auger, Doctor of Podiatric Medicine (DPM) in Sandy, Utah. As an athlete herself, Dr. Auger is the perfect connection for those of you who love hiking, trail running, snowshoeing, and the myriad of popular activities available in this region.
Dr. Auger intentionally chose Sandy for her practice and established a convenient location for patients. Why? Because she gets to live in a place she loves; which offers plenty of outdoor activities, and the opportunity to help improve the lives of those who reside in, and visit, Sandy!
A: When you have an ingrown toenail you’ll experience some discomfort on the side of the offending nail border. There may be some swelling and also some redness in the area. So pain, swelling, and redness; it can be one of these or all three.
A: It most certainly can. There are other conditions which may present with similar symptoms:
However, the most common condition is just going to be the ingrown toenail, and we know that this can be diagnosed at the time of the visit.
A: There could be multiple causes, but the most common one occurs by just trimming your nails too low down in the corner; when the nail grows back it can end up embedded into the nail fold. Usually, we see this when people have trimmed their own nails really short, or maybe they went for a pedicure and the nail technician cut them very short down in the corner.
Perhaps during an activity, they tore a part of the nail off and now it’s just too short in the corner. Also if you have a bunion, that’s going to force the big toe to press into the 2nd toe, which can result in an ingrown toenail on your 2nd or 1st toenail. Another thing which may provoke this condition is wearing very tight shoes or even tight socks. Hammertoes may also cause an ingrown toenail.
A: Initially, if you have some discomfort, I always recommend that you do a warm, soapy water soak with some Epsom salts. While your foot is soaking, you can go ahead and try to pull the offending nail fold away to open up the nail at the pocket. Giving the nail some more room may also allow for any drainage to come out.
It’s really important to follow your soak with an antibiotic ointment, and applying a band-aid; versus just leaving it exposed. Beyond that, I don’t recommend using a tool to cut it out yourself because this could lead to a bacterial infection and even become septic!
If you follow the remedies I’ve mentioned above (soaking, topical antibiotic, bandage) without improvement in 1-2 days, you need to see a podiatrist and have it treated in the office!
A: You may not notice the toe is red or swollen because you have been wearing shoes or socks but eventually you will notice the pain and how it is relieved once you remove those items from your feet.
A: My first concern would be how long it’s been going on, and how swollen the toe is. If there is any drainage in the area or an odor (we call it malodor) it tells me there is possibly an abscess that needs to be drained. If this the case I may put you on antibiotics; it just depends as every case is individual.
Anything else that you would be looking for?
Any redness that is spreading beyond the toenail. If that redness is creeping up the toe and going more proximal that is a big red flag. You may now have more than an ingrown toenail! You have more than an ingrown nail, you now have cellulitis that may need IV antibiotics and surgical intervention in a hospital setting.
A: The procedure that I do in the office is what we call a matrixectomy and what this involves is removing the offending nail border. I also clean out the area underneath the nail fold and inspect it for any type of abscess or drainage that needs to come out.
Afterward, then I place a chemical on the nail root to dissolve it which prevents that corner nail from growing back. In that case, during the procedure, I will trim the excess flesh back.
The chemical is called phenol and it is neutralized by blood. So for this procedure, I must put a tourniquet on the toes to make sure there’s no blood in the area. This will minimize the recurrence rate.
There are other procedures that are very rarely necessary. Sometimes, I will have a patient come in with a bulge of soft tissue or fat around the nail which presents as a nail fold that’s really large. In this case, during the procedure, I may just go ahead and trim that off and trim it back.
What they used to do is use more of a scalpel approach to go in and cut out the nail root; removing anywhere from 1 to 4 millimeters of the skin around the nail and then suturing it up. That’s a long healing process, and also, when you’re doing that much you may even increase the risk of infection; you now have a wound that’s exposed and takes longer to heal.
A: Yes. That said, I’ve had some patients tell me that the doctor placed them on antibiotics only to have the come a week later to cut the nail back, and then to return a 3rd time for application of the chemical. Some will just have you come in and cut out the nail, but they won’t put apply the chemical; they want you to return a week later to apply that. I just think that approach is an unnecessarily long, drawn-out, and very expensive process for the patient.
I’m sure most patients would rather do it all at once, especially if it could get worse!
Some patients will call and say, “So, will she do this on the first visit?” Yes, absolutely I will. The reason they ask is that they have a history of knowing that some doctors will not do this on the first visit. Multiple visits are more costly, and a time-consuming process for the patient.
A: Essentially, you have a piece of nail sitting underneath the nail fold. There’s no other way to remove it, and if it stays there you will have continuous chronic infection.
So if I have a patient who calls up and says, “I have an ingrown toenail and I went to the InstaCare and they put me on an antibiotic and said I should follow up with a podiatrist.” The thing is with that antibiotic, it will clear up their pain, their swelling, and their redness but if the nail root is not removed, it will recur over and over. So, the follow-up part is absolutely essential.
So basically it sounds to me like what you’re saying is that surgery is the way to take care of this 100 percent because it will get worse without it, right?
Yes. The thing is, I am always a little bit cautious about calling it a surgery. I mean, I prefer to call it an in-office procedure because some people hear the word surgery and they think, “Oh no, I have to go to the hospital and someone has to drive me and I have to take pain medications, and I have to take time off of work.” And, it’s nothing like that.
A: Well, first of all, they can go right back to work immediately afterward if they want to come during their lunch and have it done. After the procedure, they will have less pain. What they can expect is that after the procedure their toe will be numb for the first 2-3 hours. They are required to soak it up to 3 times a day until their follow up visit; which is between 10-14 days after the procedure. If post-procedure pain control is necessary, they can ice the area and take an Ibuprofen 600 mg every 8 hours as needed.
Some patients come in for their follow up and they have healed really fast, and are 100 percent better. Sometimes, when they come in they need to have some scabbing removed out of the surgical area, and that’s just a simple thing. Or it may require taking a Q-tip and cleaning it out to make sure that there is a gap between the nail and the skin where the dissolved nail root can drain out.
So a big thing is the soaking. If they do not soak their foot, the dissolving nail root will get caught underneath the skin and can cause pain, and redness, and swelling. The healing process really depends on how compliant the patient is. I’ve seen it take anywhere up to 4 weeks, but usually, patients are good within 10 to 14 days.
A: No, to me that’s the whole point of doing the matrixectomy procedure — so as long as I use that tourniquet, and keep the blood out of the area it will not neutralize the phenol before it has a chance to work. This is the most definitive plan which is going to give you the best success rate, but there is always that chance that it will be recurrent.
A: Of course. I do have patients comment immediately after the procedure, “That’s it? I should have had this done 10 years ago.” I think one of the biggest things with people is that they’re actually scared of the shot. There are four nerves in the big toe that I need to numb up, but the injection takes less than a minute — and after that your toe is numb and you don’t feel anything.
A: If you think about it, this can go on and on for years. The pain of digging the nail out and the possibility of a grave infection. Instead, the patient could have just set aside 30 minutes to have the procedure and a permanent fix. I encourage people to make an appointment to have their ingrown toenail resolved.
Compared to all the time that you can spend on it, and all the risk that you’re taking, I just encourage people to come in and get it done. It’s a little bit of pain and a whole lot of comfort afterward.
Sometimes people think they’re going to lose their entire nail but that’s not the case. Also, if you’re pregnant the procedure isn’t a problem and you certainly don’t want an infection while you’re pregnant.
Knowledge is power, and I believe that people can take the truth when they hear it. Thank you for taking the time to share your knowledge, Dr. Auger.