Ingrown Toenail Care in 1908 and Now

Flipping through the 1908 textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD I found at an antique store last month, I came across the section on ingrown toenails. The causes of ingrown toenails were much the same as one hundred years.

This is a condition in which the edge of the nail, usually of the great toe, by its too close contact with the flesh beneath causes irritation, ulceration, or suppuration. There has been much discussion as to whether the nail or the flesh is the more at fault. This discussion is without profit. It is much better to study the normal conditions, and see what can be done to restore them. Figure 292, A and B, shows the normal toenail in longitudinal and transverse section. The drawings are from the toe of a young male adult. It is important to note the relations of the matrix of the nail to the first phalanx and to the joint; since the bone and joint are landmarks in the performance of the operation for the cure of the ingrown nail.

If the nail is allowed to grow out to the end of a normal toe, the ordinary pressure of the shoe brings the edge of the nail against the underlying skin at the end of the toe where the skin is tough, so that no damage results. If an ill-fitting shoe constantly rubs the toe, or if some one steps on it, the trauma may break the underlying skin. The edge of the nail will then be in constant contact with the sore, and will act like a foreign body, and prevent the ulcer from healing.

This is especially true if the corners of the nail have been cut away, so that the pressure of the nail’s edge comes on the more delicate skin by the side of the nail, rather than on the tougher skin at the end of the toe. The resulting inflammation, ulceration, and granulation may go on until the toe presents the appearance shown in Figure 293.

Such a toe is very painful, and the pain is only partly relieved by cutting away the upper of the shoe, etc. As there is an easy exit for the discharge, infection rarely extends upward into the foot and leg. On the other hand, the conditions for repair are not good, so that a patient may go hobbling about for months with a small ulcer under the nail’s edge, marked by an exuberant growth of granulations and a slight discharge.

Note: Today the common causes of ingrown toenails are still listed as wearing shoes that crowd your toenails, cutting your toenails too short or not straight across, injury to your toenail, and unusually curved toenails.

Prevention begins with those causes. To prevent ingrown toenails, it is important to wear shoe that fit properly and don’t pinch. It is important to trim your toenails straight across. It is important to protect your toes from injury, so wear steel-toed shoes if needed.

Treatment – There are three ways to cure the exiting ulcer of an ingrown nail: (a) One is to interpose some protecting material between the edge of the nail and the ulcer; (b) another is to remove the edge of the nail from the ulcer; and (c) the third is to remove the flesh from the edge of the nail.

In mild cases the ulcer due to an ingrown nail may be cured by depressing the flesh along its edge and pushing a small wisp of absorbent cotton under it. This should be wet with some astringent solution, for example, silver nitrate, 1:50. The upper of the shoe should be cut from the sole far enough to relieve the great toe from pressure. The dressing should be changed every day or two. Cotton should be kept under the edge of the nail until the corner of the latter has grown out to the end of the toe. Otherwise the ulcer is likely to reform.

The nail can be pushed upward away from the ulcer by means of a littler silver hook. A thin strip of spring silver is so bent that it will hook under the edge of the nail, and then half encircle the toe, on its plantar surface. As the patient steps on the toe the buried edge of the nail is lifted upward. The hook is kept in place by adhesive plaster or a bandage. This method, like that of cotton and astringents, finds its best use in mild cases occurring in people of some intelligence.

The first one mentioned is actually considered part of the current day’s “home care” suggestions:

• Soak the foot in warm water three or four times each day.
• When not soaking, make sure the foot is clean and dry.
• Carefully wedge a small piece of clean cotton or waxed dental floss between the skin and the toenail. Be sure to change this packing daily.
• Wear open-toed sandals or similar while the condition heals. Otherwise, opt for comfortable shoes that don't squeeze the toes.

Moving along to the second and third treatments for more severe cases.

The edge of the nail may be pared away, and so separated from the ulcer. This is the treatment of many patients as well as chiropodists. It often gives temporary relief if the ulcer does not extend too near the matrix, but it can cure only mild cases of ingrown nail, for as the nail grows out its corner digs again into the flesh. For the same reason, “tearing out by the roots” the whole or a part of the nail is doomed to failure. The matrix cannot be torn out, and will grow another nail at least as distorted as its predecessor.

A satisfactory radical operation must remove, with the edge of the nail, that portion of the matrix from which it grows. The details of this operation are as follows: Cleanse the toe as thoroughly as possible with soap and water and an antiseptic solution; shut off the blood-supply of the toe by a bandage tied about its narrowest part. Inject a local anesthetic along the edge of the nail and beneath it as far back as the base of the second phalanx. Cut through the nail and overlying skin in a line parallel to the axis of the toe. This cut should separate from the nail a strip about one-fourth of an inch wide, and should extend clear through the matrix of the nail – a dense white layer easily differentiated from the subcutaneous fat. The overlying skin at this side should be dissected free from this separated marginal strip of nail and from its matrix.

This strip of nail and matrix should be dissected out by cuts made above and below it, and meeting well beyond it under the skin at the side of the toe. The surgeon should remember that the nail grows from the thick layer of epithelial cells placed both above and below the plane of the nail, the former extending nearly to the reflection of skin, and the latter extending to the white semilunar line. The skin flaps are retracted and the wound is inspected for any possible bit of matrix which may have been left. It is then well wiped out with an antiseptic solution, such as a solution of bichlorid, 1:2,00, and closed by the pressure of a wet dressing wrapped around the toe; ligation of blood vessels is rarely necessary, especially if the dressing is partly applied before the constricting bandage around the toe is removed. Too great pressure must not be applied to the lateral flap, however, lest sloughing or infection follow. The shape of the wound facilitates drainage if a wet dressing is put on and frequently moistened. The dressing should be changed daily for four days; then if all is well, a dry dressing may be substituted and changed again every three or four days. If the wound heals as it should, it will be quite closed in ten days. The proximal half usually closes by “first intention.” Sutures may be inserted, but are not necessary.

The disfigurement after this operation is slight, and the functional result is perfect.

In performing the above described operation, one should bear in mind that every bit of the nail has its corresponding portion of the matrix from which it springs and that growth of the nail, except in cases of distortion, is parallel to the long axis of the toe. One should not, therefore, remove a broader portion of the matrix than will correspond to the buried portion of the nail. When this rule is followed, the visible portion of the nail will continue to be formed and normal appearance of the toe will be preserved.

If a portion of the matrix is left in the operative field, it may grow up by the side of the nail in harmless stubs of nail, or, if larger, it may grow a long spike of nail which pierces the skin at the side of the toe and renders a second operation necessary, or it may be unable to pierce the skin and will then curl up, forming a subcutaneous mass of half hardened epithelial debris.

The operation above described has been developed in the hands of the author from several cruder ones, based on the same principle, of removing the matrix of the offending portion of the nail. Some of them were less certain in accomplishment, and some more painful in execution, and some more mutilating. Some operators, in addition to the removal of the matrix of the involved part of the nail, tear out the whole formed nail. This has no advantage, and renders the toe more or less sensitive for some weeks.

The third method of separating the edge of an ingrown nail and the ulcer it causes, is by removal of the ulcer. This is accomplished by cutting away the skin and subcutaneous tissue of the side of the toe. As there is then nothing for the nail’s edge to press against, the soreness quickly disappears. The wound left to granulate is from half an inch to an inch in diameter; so that healing takes a month to six weeks. The ultimate result is good, but the shape of the toe is somewhat altered in appearance. This operation bears the name of Cotting.

Anyone with diabetes or circulation problems are at greater risk of complications from an ingrown toenail. Do not hesitate to be seen by your physician if you have diabetes or a foot circulation problem and develop an ingrown toenail.

It is important to began care of an ingrown toenail as soon as it's recognized. You should start to see improvement within two or three days. If you don't, contact your doctor.