List of Abbreviations
IT | ingrown toenail |
|---|---|
CAD | coronary artery disease |
CT | computed tomography |
MRI | magnetic resonance imaging |
DM | diabetes mellitus |
CRF | chronic renal failure |
CHF | chronic heart failure |
SW | surgical wound care |
Terms and Definitions
An ingrown toenail (onychocryptosis) is a condition in which the nail plate grows into the lateral edge of the periungual fold, leading to its inflammation. In children, it most commonly occurs as a result of a mismatch (imbalance) between the size of the nail plate, nail bed, and periungual tissues.
Keratinocytes are the cells that form the epidermis.
Onychogryphosis is a pathological condition in which the toenails become deformed, thickened, curved, bent, and resemble bird claws or ram horns.
Onycho-dystrophy is a collective term used to describe disorders of the nail apparatus accompanied by changes in the color, shape, or structure of the nails. The most prominent manifestations of onychodystrophy are nail brittleness and its detachment from the nail bed.
Onycholysis is a condition in which the nail plate separates from the nail bed, posing a risk of trauma and infection to the nail bed.
Onychomalacia is a condition characterized by pathological softening of the nail plate (often a symptom of systemic processes such as liver disease, metabolic disorders, nutritional deficiency, malabsorption, or hyperhidrosis).
Onychomycosis is a fungal infection of the nail plates.
Onycotillomania is a compulsive behavior inซึ่ง a person continuously picks at the nails or attempts to pull them off.
Onychoschizia is transverse splitting of the nail plate without signs of inflammation.
Orthonyxia is a non-surgical orthopedic method for correcting the shape and growth direction of the nail plate using corrective systems (braces, plates, polymer composites).
Paronychia is acute or chronic inflammation of the perionychium of the fingers, and less commonly the toes.
Nail spicule is an excessively protruding part of the nail plate shaped like a pointed spike directed distally and laterally, formed as a result of improper trimming of the edge or corner of the nail plate. During normal growth of the nail plate, the nail spicule (spike) "pierces" and grows into the lateral nail fold.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Ingrown toenail — (IT, onychocryptosis, unguis incarnatus, ingrown nail; syn. nail incarceration), the pathological ingrowth of the lateral margin (the distal margin and proximal margin in the variant of retronichia may also be involved) of the nail plate into the soft tissues of the digit, leading to the development of chronic inflammation in the nail fold area and accompanied by a combination of morphological and functional changes in the nail plate, its matrix, and the soft tissues of the digit; the cascade of inflammatory and reparative processes in this case may become either chronic or cyclical (most frequent localization is the lateral margin of the hallux) [1].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The direct cause leading to the development of an ingrown toenail is acute or chronic trauma to the nail plate with damage to the matrix and subsequent disruption of its growth, as well as damage to the surrounding tissues [1, 2].
The following factors predispose to this condition:
– deep cutting of the free and lateral margins of the nail plate toward the base (non-professional pedicure);
– foot deformities, primarily of the hallux, due to flat feet, surgical interventions involving damage to the nail matrix, hallux valgus;
– redistribution and increase of load on the hallux (starting to wear high heels, wearing narrow shoes, obesity, pregnancy, occupational features);
– changes in the structure of the nail plate due to onychomycosis and hyperhidrosis;
– systemic diseases leading to metabolic disorders (diabetes mellitus, psoriasis, gout, chronic heart failure);
– in children, the main cause of nail plate ingrowth is a disruption of normal growth and anatomical disproportion between the nail plate, nail bed, and surrounding soft tissues;
– pathological curvature (curvature) of the nail plate on one or more sides (an excessively flat nail plate creates pressure on the periungual tissues or a curved "pincer" nail plate creates a pinch of the subungual tissues with the formation of an ingrown toenail);
– unsuccessful previous surgical interventions on the nail apparatus (use of total ablation, inadequate conservative treatment);
– excess weight (formation of excessive pressure on the periungual tissues and disruption of normal nail plate growth);
– toe and metatarsal formula (Greek or Egyptian formula with a short or excessively long hallux relative to the second toe causes pathological changes in the forefoot with the formation of a mechanical conflict between the toes and the ingrown toenail);
– significantly less frequently, usually in the first life year, the cause of an ingrown toenail is its congenital deformation;
– mental illnesses (onychotillomania, onychophagia) [3].
The microbial landscape in ingrown toenails is in most cases represented by Staphylococcus aureus and hemolytic Staphylococcus (up to 35% of cases), Streptococcus (5–10%), and gram-negative flora (7–20%). The proportion of pathogenic fungi is high (up to 40%). Purulent-inflammatory processes are most often caused by microbial associations represented by fungi and aerobic-anaerobic pathogens (20–30%) [1, 2].
Paronychia associated with lateral embedding of the nail plate and the formation of granulomas causing an ingrown toenail can occur as a side effect of antiretroviral drugs (systemic antiviral drugs), EGFR (epidermal growth factor receptor) inhibitors, and systemic retinoids (systemic medications for acne treatment) [4].
Various theories regarding the pathogenesis of ingrown toenails have been proposed, which can be divided into two groups depending on whether the problem arises from the nail itself or is caused by the soft tissues surrounding the nail.
The main reason for unsatisfactory outcomes of most surgeries, according to literature data, is that the methodology of their execution is based on entrenched misconceptions regarding the etiology and pathogenesis of ingrown toenails, according to which the nail supposedly grows into the tissues of the lateral nail folds. In reality, the nail plate grows only in length, while its width is genetically determined [5].
It is believed that one of the main predisposing factors for the development of an ingrown toenail is a congenital or acquired expansion of the germinative matrix band, i.e., the germinative layer of the nail plate, which is located behind the posterior nail fold. A wide germinative zone leads to the formation of a wide nail plate. If such a plate curls sideways perpendicularly to the axis of growth during the growth process, a conflict may arise between the edges of the nail plate and the lateral nail folds. This conflict leads to the appearance of a chronic, long-healing wound with the secondary addition of a bacterial infection. In the absence of timely treatment, granulation tissue proliferates in the lateral nail folds, which, hanging over the nail plate, deforms the nail phalanx of the digit [6, 7].
According to another hypothesis, an ingrown toenail develops due to pressure on the nail from the side or from the dorsal side of the digit, which is amplified by ill-fitting footwear. People with naturally curved nail plates are more susceptible to this condition [8, 9].
Improper nail trimming technique is a well-known risk factor for ingrown toenails. Trying to excessively "round" the corners of the nails, patients may unintentionally lead to deep ingrowth of the nail plate (due to the formation of a nail spicule) as it grows into the lateral part of the nail bed. Compression of the toe can lead to wrinkling of the nail bed and impede nail growth. It is often difficult to achieve pain relief that exacerbates this condition, as removing the spicule also requires cutting the soft tissues [10].
Trauma is another recognized risk factor for the development of ingrown toenails. Blunt force impact during walking combined with tight shoes or foot edema can lead to the penetration of the nail into the periungual fold. Patients with a second toe length equal to or exceeding the length of their ipsilateral fold have an increased incidence of ingrown toenails associated with laterodistal shoe pressure on the nail fold [11–13].
Obesity can contribute to the development of ingrown toenails with an increase in soft tissues throughout the body and lower extremities, mimicking periungual hypertrophy and increasing shoe compression. A wider gait in obesity can increase pressure on the nail folds, which can lead to occult trauma and progression of the ingrown toenail. Similarly, diabetes mellitus, as well as thyroid, heart, and kidney diseases, can increase lower extremity edema, mimicking the effect of obesity on the nail apparatus [11].
The shape of the nail matrix is closely related to the morphology of the dorsal surface of the distal phalanx. An elevated distal phalanx can injure the nail plate and deepen the nail groove, thereby creating a mismatch between the nail plate and the lateral or distal nail fold and contributing to the development of onychocryptosis. In addition, abnormal hallux valgus deformity correlates with a higher prevalence of ingrown nails [14, 15].
Hyperhidrosis can contribute to the development of ingrown nails on the feet, as the integrity of the periungual skin may be compromised due to maceration. This is particularly noticeable in adolescence, when excessive foot sweating is quite common, increasing the flexibility of the nail plates and facilitating skin perforation [12].
Onychomycosis with concomitant hyperkeratosis can lead to the destruction of the nail plate with the formation of "nail spikes", which can damage the surrounding skin [16].
The thickness of the nail plates can become a risk factor due to a decrease in their flexibility, but it has also been suggested that increased flexibility of thin and flattened nails increases the risk of ingrown nails [17, 18]. In other words, any variants of onychodystrophy can lead to the appearance of ingrown nails.
1.3 Epidemiology of the Disease or Condition
According to various data, ingrown toenail accounts for 3.0 – 10.0% of the structure of total morbidity and is one of the most frequent reasons for seeking medical care from an outpatient surgeon (from 0.5% to 10.0% of patients). This condition is more common than osteomyelitis, phlegmon, or lower extremity abscess. More than 80.0% of patients suffering from ingrown nails are young people of working age. The specific course of the disease, the recovery period after treatment, and the frequency of relapses often lead to persistent, prolonged disability and a reduced quality of life [19]. In children, the peak incidence occurs at the age of 10 – 15 years [3].
Ingrown nails occur almost exclusively on the big toes, which are more frequently injured during walking, and can occur on one or both edges of the nail. Involvement of the lateral edge of the nail is twice as common as the medial edge, which correlates with the fact that it bears the main weight-bearing load [10, 20, 21].
The prevalence of ingrown toenails and epidemiological data are scarce. Information on ingrown nails is likely underreported, as patients are unlikely to seek medical attention if they have mild symptoms of the disease [1]. Although no significant differences in race and ethnicity were identified among patients with ingrown nails, low rates of the condition are observed among populations that do not wear shoes [22, 23].
In patients with diabetes mellitus, ingrown nails occur in 13.0 – 32.0%. In diabetics and patients suffering from impaired arterial blood flow and decreased sensitivity in the lower extremities, severe purulent complications and even gangrene can join ingrown nails [11, 12, 24].
1.4 Features of Coding the Disease or Condition
L60.0 - Ingrown nail
1.5 Classification of the disease or condition
One of the first was the classification developed by podiatric physician C. Heifetz (1937) [25]:
Stage | Clinical presentation |
|---|---|
I | Mild erythema, edema of the periungual sinuses in the nail bed |
II | Acute infection, suppuration |
III | Chronic infection with granulation tissue formation and/or hypertrophy of periungual tissues |
Modern internationally recognized classifications of ingrown nails include the classification developed by podiatric physician Dr. John Mozena (2002):
Stage | Clinical presentation |
|---|---|
I | Erythema, moderate edema, pain on pressure to the nail fold |
IIa | Worsening of stage 1 symptoms, presence of infection and exudate with nail fold overgrowth over the nail plate < 3 mm |
IIb | Worsening of stage 1 symptoms, presence of infection and exudate with nail fold overgrowth over the nail plate > 3 mm |
III | Worsening of stage 2 symptoms, presence of granulation tissue and hypertrophy of periungual tissues |
And the classification developed by podiatrist Martinez-Nova (2007) [26]:
Stage | Clinical presentation |
|---|---|
I | Erythema, edema, pain on pressure to the nail fold, sensation of pressure on the nail fold |
IIa | Increased pain, edema, erythema, hyperesthesia, appearance of exudate and/or infection. Overgrowth of the nail fold over the nail plate < 3 mm |
IIb | Increased pain, edema, erythema, hyperesthesia, appearance of exudate and/or infection. Overgrowth of the nail fold over the nail plate > 3 mm |
III | Presence of granulation tissue and chronic hypertrophy of the nail folds. Granulation or hypertrophic tissues cover a large part of the nail plate. |
IV | Pronounced chronic deformation of the nail plate and nail folds on both sides. Hypertrophic tissue completely covers the lateral, medial, and distal edges of the nail plate. |
The main modern classification used by the international podiatric community is the Kline classification (2008), developed by podiatric physician A.L. Kline [27]:
♦♦ Stage I — local irritation of the nail fold without signs of infection or granulation tissue, with or without a history of onychocryptosis;
♦♦ Stage II — infection of the nail fold with purulent discharge and/or granulation tissue, no history of onychocryptosis;
♦♦ Stage III — infection of the nail fold with purulent discharge and/or granulation tissue, history of more than one episode of onychocryptosis of the affected nail edge;
♦♦ Stage IV — infectious onychocryptosis with partial onycholysis of one nail edge;
♦♦ V stage — infectious onychocryptosis, with partial or complete onycholysis of the nail plate, affecting both edges.
1.6 Clinical presentation of the disease or condition
The main symptom is usually discomfort or pain in the area of the ingrown nail, which increases when walking, putting on shoes, or pressing on the affected area. The symptoms of an ingrown nail develop progressively. Later, other symptoms join:
– tissue swelling;
– redness of the area around the nail;
– deformation, thickening, dullness, and detachment of the nail plate;
– weeping/maceration;
– a sensation of fullness or throbbing.
The pain only intensifies over time, sometimes even appearing at rest. This indicates the progression of the inflammatory process. Without treatment, suppuration and the spread of the focus to other areas may occur.
In mild ingrown nails, there are local clinical signs – edema, minor pain, sensation of fullness, redness.
In moderate ingrown nails, a bacterial infection joins. The tissues around the nail are hyperemic, infiltrated, hypertrophied, and granulation tissue may form.
In severe cases, periungual tissues and the nail bed are deformed, and a scar is formed. Purulent discharge begins, and complications arise.
Without timely initiated treatment, an abscess with dense perifocal edema forms on the toe. The toe becomes sharply painful. The pain does not subside at rest.
Further complications are associated with pre-existing chronic diseases – diabetes mellitus, thrombophlebitis, severe atherosclerosis. Frequently, these patients may develop osteomyelitis of the nail phalanx, toe gangrene, lymphangitis, or lymphadenitis. A rarer complication is generalized infection, sepsis.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Diagnostic criteria
The diagnosis of an ingrown nail is established based on the following data:
– Anamnesis.
– Complaints of pain and discomfort in the area of the affected toe.
– Data from physical examination and assessment (presence of signs of an ingrown nail - redness, tenderness of periungual tissues, presence of a wound in the nail sinus, exudate, proliferation of granulation tissue of the nail fold, deformation/thickening of the nail plate).
2.1 Complaints and Anamnesis
In all patients with suspected ingrown nails in order to establish the diagnosis, it is recommended to pay attention to constant intense pain in the area of the nail fold, worsening when walking and wearing shoes [1].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
Comment: in the diagnosis of ingrown nails during anamnesis and examination, the following should be taken into account:
♦♦ Occupational hazards — prolonged standing, static-dynamic overloads, wearing specialized narrow, ill-fitting, athletic shoes that do not take into account the anatomical features of the feet and the specifics of physical loads.
♦♦ Lack of a culture of nail and foot skin care — poor foot hygiene, fungal infection, infected corns and fissures, hyperhidrosis, improper cutting of the nail edge, poor-quality pedicure with gel-polish coating, continuous wearing of tight stockings, including compression medical knitwear like tights (with a closed toe) for the prevention of thromboembolic complications.
♦♦ Anatomical prerequisites — hallux valgus, osteoarthropathy in diabetes mellitus, anatomical features of nail plates and nail folds — large fleshy overhanging lateral folds, arched nail plates, congenital/acquired deformities.
♦♦ Chronic non-communicable diseases — excess weight and obesity, various forms of flat feet, obliterating diseases of the lower extremity arteries, metabolic disorders including diabetes mellitus, genetic predisposition, immunodeficiencies, acute and chronic trauma to the nail plate [19].
2.2 Physical Examination
All patients with suspected ingrown toenail are recommended to undergo an examination by a surgeon (initial examination/consultation by a surgeon, initial examination/consultation by a pediatric surgeon) including palpation of the affected toe to determine the stage of the lesion and the localization of the purulent-destructive focus [1].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
Comment: the examination should identify anatomical features, the stage of the disease development, the presence of complications, and include a comparative examination of the contralateral limb. The characteristic appearance of the toe allows for an easy diagnosis and determination of the severity of the process. During the examination, it should be kept in mind that the key signs of an ingrown toenail are edema of the lateral or medial periungual fold, often accompanied by purulent discharge and granulation tissue development. The lateral edge of the nail plate must be assessed to determine its penetration into the periungual tissues. It is necessary to evaluate the presence of signs of inflammation in the affected area and purulent discharge. It is important to ascertain whether conservative or surgical treatment for the ingrown toenail has been performed previously and what kind [16, 28, 29].
2.3 Laboratory Diagnostics
In patients with an ingrown toenail, general clinical tests are recommended in the presence of a systemic host response or a relapsing course of the disease (fever, tachycardia, tachypnea), in the volume of a complete blood count with differential white blood cell count, routine urinalysis, and general therapeutic biochemical blood analysis, to assess the patient's general condition during the diagnostic period and treatment, as well as to detect comorbid conditions [4, 45].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
In patients with an ingrown toenail, blood glucose and glycated hemoglobin testing is recommended if diabetes mellitus is suspected, in order to timely detect it [30].
GCR CLEL 4Grade of Recommendation C (Level of Evidence - 4)
Microbiological testing (microbiological (culture) examination of purulent discharge for aerobic and facultatively anaerobic microorganisms, molecular biological examination of the discharge from affected skin areas for methicillin-sensitive and methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus spp.) is recommended in the presence of purulent discharge to determine the pathogen and its antibiotic susceptibility (determining the susceptibility of microorganisms to antimicrobial chemotherapy drugs) in case of a prolonged relapsing course of the disease and ineffective therapy, in order to select specific treatment [4, 45].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
If onychomycosis is suspected, it is recommended to take a scraping from the affected area with fungal culture (microbiological (culture) examination of wound discharge for fungi (yeasts, molds)) to confirm the diagnosis [31].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
2.4 Instrumental Diagnostics
All patients (adults and children) with an ingrown toenail should undergo radiography of the affected toe (radiography of the phalanges of the toes) in two projections only if there are clinical data indicating potential bone involvement in the inflammatory process [21, 32].
CUD CLOE 5Level of Certainty of Recommendation C (Level of Evidence - 5)
Comment: in chronic deformation of the nail plate, imaging (radiography of the toe phalanges) is advisable to identify local bone changes that may exert pressure on the nail matrix (various conditions such as osteomyelitis, benign tumors (subungual exostosis, osteochondroma), and malignant tumors (squamous cell carcinoma, subungual melanoma) can present with symptoms similar to an ingrown toenail) [32].
In addition, radiographic examination of the feet is advisable to clarify the anatomical features of the foot (the degree of hallux valgus deformity, assessment of the degree of flatfoot).
In patients with an ingrown toenail against the background of diabetes mellitus or lower extremity peripheral artery disease, the likelihood of purulent-necrotic complications increases; therefore, before starting treatment, they should undergo an ultrasound examination of the arteries and veins of the lower extremities (Doppler ultrasound of lower extremity vessels (arteries and veins)) [16, 28, 29].
2.5 Other Procedures
In rare cases, in the presence of severe deformity and a chronic relapsing course of an ingrown toenail, morphological examination of the removed material (pathological anatomical examination of skin biopsy (surgical) material) is indicated to rule out neoplastic lesions [48, 49].
Level of Evidence CGrade of Recommendation 5Level of Evidence C (reliability grade of evidence - 5) – children.
Level of Evidence CGrade of Recommendation 4Level of Evidence C (reliability grade of evidence - 4) – adults.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
The treatment strategy for an ingrown toenail includes conservative as well as palliative and radical surgical interventions. Therapeutic tactics primarily depend on the stage of the disease. For stages I-II, conservative methods are preferred, while for stages III-IV, surgical methods are preferred [33-37].
Comment: conservative treatment is mainly effective for acute episodes of nail plate ingrowth and is associated with a high recurrence rate because it does not eliminate the root cause. Indications include stage I-II ingrown toenails (mild to moderate acute inflammation) resulting from a temporary alteration of the nail plate (e.g., after improper trimming and formation of a nail spicule) or when the nail apparatus is not yet fully formed (in infants and small children). Another reason for choosing conservative treatment is the presence of conditions that preclude surgical treatment.
3.1. Conservative management
Patients (adults and children) with stage I-II ingrown toenail (mild and moderate acute inflammation) are recommended conservative treatment [33, 34, 37].
Level of Evidence AGrade of Recommendation 1Level of Evidence A (reliability grade of evidence - 1)
Comment: in patients with an ingrown toenail without hypertrophied granulation tissue, prominent inflammation, or severe local pain syndrome, it is advisable to start treatment with conservative methods. These include local offloading (wearing appropriate shoes in width and size, toe spacers to increase the distance between them, custom orthotic insoles), nail care, including the treatment of hyperhidrosis and fungus in case of onychomycosis [38].
It is important to maintain hygiene (washing feet with toilet soap – not laundry soap and not shower gel), followed by the application of topical steroid ointments (corticosteroids used in dermatology) for 1–2 weeks [34]. Urea has a keratolytic (exfoliating) and moisturizing effect – it helps retain moisture in the epidermis and also suppresses the excessive activity of keratinocytes, the cells that form the epidermis. Creams with 10% urea are used in patients with early-stage ingrown toenails to soften the nail plates and facilitate their treatment and trimming. Packing medical cotton, medical gauze, or non-woven synthetic materials ("capolin", "ligasano") under the nail edge can be performed to correct the direction of nail edge growth and mechanically separate the nail plate edge from the nail fold. The use of ortonyxia using special systems to correct the shape of the nail plate and the direction of nail edge growth is particularly effective [16]. These measures should be applied sequentially for 2–12 weeks, depending on the severity of the process and the response to therapy [34].
In addition, the need to correct systemic metabolic disorders, if present, is obvious.
In patients with an ingrown toenail, routine use of systemic antibacterial drugs is not recommended [34].
GCR ALOE 1Grade of Recommendation A (Level of Evidence - 1)
Comment: the presence of an ingrown toenail involves regular topical treatment – dressings and wound care. For this purpose, after washing the affected area with warm water and soap, treatment with an antiseptic solution (water-based antiseptics and disinfectants that do not stain the skin and do not contain acids or alkalis) is performed, after which local application of ointments containing antiseptics (antiseptics and disinfectants) or broad-spectrum antibacterial agents (with mupirocin, bacitracin + neomycin, dioxomethyltetrahydropyrimidine + chloramphenicol (contraindicated in children under 1 year), povidone-iodine**) is possible.
In patients with an ingrown toenail and signs of abscess formation and/or generalized infection, the use of systemic antibacterial drugs selected based on the results of microbiological testing is recommended [38-41].
Level of Evidence BGrade of Recommendation 2Level of Evidence B (reliability grade of evidence - 2)
3.2. Surgical treatment
In patients with stage III-IV ingrown toenail, surgical treatment is recommended [33, 34, 42, 43].
GCR ALOE 1Grade of Recommendation A (Level of Evidence - 1)
Comment: in moderate-to-severe acute nail bed suppuration or chronic suppuration, surgical intervention provides adequate debridement of the affected focus and prevents recurrence. Surgical treatment methods can be divided into palliative nail-sparing operations (marginal nail plate resection without matrixectomy) and extended radical surgical interventions [33, 44]. Palliative interventions are generally a temporary measure and are associated with a high recurrence rate. Radical surgical interventions involve wedge excision of the affected nail part, hypergranulation of the nail fold, part of the nail bed, and nail matrix. There are numerous variants and modifications of radical interventions for ingrown toenails; one of the most common is wedge resection of the nail plate and periungual fold (roll) according to the A. Winograd technique / Schden procedure (Fig. 1) [1].
Fig. 1. Diagram of the wedge resection of the nail plate with the matrix and periungual fold (roll).
Surgical treatment is generally performed under Lukashevich-Oberst conduction anesthesia; however, in certain cases, total intravenous anesthesia with preservation of spontaneous breathing is possible [33, 34].
After the intervention and suturing, it is advisable to treat the wound with an antiseptic solution (antiseptics and disinfectants) (aqueous povidone-iodine solution**), an antibiotic ointment, for example, dioxomethyltetrahydropyrimidine + chloramphenicol (for children aged 1 year and older), hydroxymethylquinoxalindioxide (for adults) not only for anti-inflammatory and antimicrobial action, but also to reduce trauma during the first dressing change, and apply a sterile, moderately compressive aseptic gauze bandage [45].
In patients with recurrent ING, it is recommended to perform a repeat intervention including partial matrixectomy of the nail bed of the removed nail plate (removal of the nail plate with wedge resection of the matrix) [33, 34, 46].
GCR ALOE 1Grade of Recommendation A (Level of Evidence - 1)
Comment: additional laser, radiofrequency treatment, cryo-, or electrodestruction of the bed of removed tissues is not advisable [46]. Abroad, chemical matrixectomy with phenol is actively used along with surgical or electrosurgical excision to prevent recurrence [33].
In children with ING, it is recommended to perform a marginal resection of the nail plate with destruction of the nail bed matrix (removal of the nail plate with wedge resection of the matrix) in order to prevent recurrence [3, 47].
LoE CGoE 4Level of Evidence C (Level of Certainty of Evidence - 4)
Comment: matrixectomy can be performed with a No. 15 scalpel, a sharp spoon, as well as using laser or radiofrequency treatment [44, 47]. Wedge resection of the nail plate and periungual fold (roll) according to the A. Winograd technique / Schden procedure is indicated in case of recurrence.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Recovery times after surgical intervention for ING average 2–2.5 weeks and are associated both with wound healing and with movement limitations in the first days after surgery [34].
5. Prevention and Dispensary Observation
Preventive measures for ING include general recommendations on hygiene rules and wearing appropriately sized and fitting shoes, treatment of hyperhidrosis and onychomycosis, correction of flat feet and other foot deformities, and adequate therapy for diabetes mellitus and obesity. It is also important to teach the parents of a child or teenager the correct nail-clipping technique [35].
6. Organization of Medical Care
Medical care for ING is provided on an outpatient basis, except for complex cases of acute or chronic infection accompanied by bone tissue involvement and/or signs of systemic inflammatory response syndrome or generalized infection.
Indications for hospitalization in a medical organization
Signs of systemic inflammatory response.
Generalization of the inflammatory process.
Bone tissue involvement.
Criteria for patient discharge from the medical organization
Resolution of signs of systemic inflammatory response.
Elimination of ING signs.
7. Additional Information
The outcome of the disease or condition may be influenced by:
History of leukemia, oncological diseases, tuberculosis, or positive test results for HIV infection, hepatitis B and C, syphilis, chronic renal failure);
Severe congenital defects confirmed by history and/or objective examination, leading to impaired normal functioning and requiring correction (congenital heart defects, gastrointestinal tract, urogenital system, skeleton, Marfan syndrome, Klinefelter syndrome, Edwards syndrome, Opitz syndrome, Goldenhar syndrome, and others);
Cardiovascular diseases: post-infarction cardiosclerosis, silent myocardial ischemia, pericarditis, aortic aneurysm, grade III hypertension, effort angina, unstable angina, Prinzmetal's angina, severe chronic heart failure;
Systemic connective tissue diseases according to medical history (systemic sclerosis, systemic lupus erythematosus, systemic vasculitis, antiphospholipid syndrome, dermatomyositis, sarcoidosis, rheumatism, and others);
Type I and type II diabetes mellitus;
Obesity with a body mass index greater than 40;
Acute renal failure;
Chronic renal failure with a glomerular filtration rate of less than 30 mL/min.;
Any psychiatric disorders according to medical history;
Hematological diseases according to medical history;
Drug addiction or chronic alcoholism according to medical history;
Pregnancy/lactation period;
Use of medications: indinavir, ritonavir**, retinoids (retinoids for acne treatment), docetaxel**, cyclosporine**, and systemic antifungals.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Evaluation of compliance |
|---|---|---|
1 | Initial surgeon/pediatric surgeon consultation (examination, inspection) performed | Yes/no |
2 | General (clinical) blood test with differential leukocyte count (leukocyte formula) ordered and performed | Yes/no |
3 | Blood glucose test performed if diabetes mellitus is suspected | Yes/no |
4 | X-ray examination (radiography of toe phalanges) ordered and performed if bone involvement is suspected | Yes/no |
5 | Microbiological examination (microbiological (culture) examination of purulent discharge for aerobic and facultatively anaerobic microorganisms, molecular biological examination of discharge from affected skin areas for methicillin-susceptible and methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus spp.) performed in the presence of purulent discharge to determine the pathogen type and its antibiotic sensitivity (determination of microorganism sensitivity to antimicrobial chemotherapeutic drugs) | Yes/no |
6 | Conservative treatment performed for grade I-II ingrown toenail | Yes/no |
7 | Surgical treatment performed for grade III-IV ingrown toenail | Yes/no |
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Appendix A1. Working Group Composition
– Azarova Evgenia Sergeevna – Head of the Podology Department of the On Clinic MMC, Trauma Surgeon and Orthopedicist, President of the Non-Commercial Professional Medical Association of Specialists in Podiatry (Podiatry) "National Podiatric Medical Association"
– Anischenko Maria Alexandrovna – Candidate of Medical Sciences, Member of the Russian Society of Surgeons (RSS)
– Borisov Igor Viktorovich – Doctor of Medical Sciences, Member of the RSS, Board Member of the Regional Public Organization "Surgical Society — Wounds and Wound Infections"
– Golovanev Maxim Alekseevich – Candidate of Medical Sciences, Associate Professor
– Mitish Valery Afanasyevich – Cand. of Med. Sci., Board Member of the Russian Society of Surgeons (RSS), President of the Regional Public Organization "Wounds and Wound Infections Surgical Society"
– Paskhalova Yulia Sergeevna – Cand. of Med. Sci., Member of the RSS, Board Member of the Regional Public Organization "Wounds and Wound Infections Surgical Society"
– Razumovsky Alexander Yuryevich – Dr. of Med. Sci., Professor, Corresponding Member of the RAS
There is no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience of these clinical guidelines:
surgeons,
pediatric surgeons,
general practitioners (family physicians),
traumatologists-orthopedists,
dermatovenerologists,
endocrinologists (diabetic foot care unit).
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Table A2.1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference-standard control or systematic reviews of randomized clinical trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table A2.2. Level of Evidence (LoE) grading scale for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (prophylactic, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of randomized controlled trials with meta-analysis |
2 | Individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report or case series, case-control study |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table A2.3. Grade of Recommendation (GoR) grading scale for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (prophylactic, diagnostic, therapeutic, and rehabilitative interventions)
GOR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Appendix A3. Reference Materials
These clinical guidelines were developed taking into account the following regulatory legal documents:
Order of the Ministry of Health of the Russian Federation No. 922n dated November 15, 2012, "On Approval of the Procedure for Providing Medical Care to Adult Patients in the Profile of 'Surgery';"
Order of the Russian Ministry of Health No. 203n dated May 10, 2017, "On Approval of Criteria for Assessing the Quality of Medical Care";
Order of the Ministry of Health of the Russian Federation No. 231n dated March 19, 2021 "On Approval of the Procedure for Monitoring the Volume, Timeliness, Quality, and Conditions of Provision of Medical Care under Compulsory Medical Insurance to Insured Persons, as well as Its Financial Support" (as amended);
Letter of the Federal Compulsory Medical Insurance Fund No. 6545/30-5 dated December 30, 2014, "On Targeted Quality Appraisals of Medical Care";
Order of the Russian Ministry of Health No. 103n dated February 28, 2019, "On Approval of the Procedure and Timelines for the Development and Revision of Clinical Practice Guidelines, Their Standard Template, and Requirements for Their Structure, Composition, and Scientific Validity of Information Included Therein."
Appendix B. Physician Action Algorithms
Stage I of inflammation (erythema, mild edema, and pain upon palpation of the lateral nail fold; the nail fold does not extend beyond the nail plate) | Treatment: – General measures (hygiene, pedicure, footwear, cosmetics). – Conservative treatments are used in the absence of infection (separation method using tamponade with "kapolin", "ligazano", cotton pad, "sulcus protector"; ortonyxia method; taping method; angle correction method, etc.). – Ortonyxy systems can be used in the absence of infection, hemorrhage, or DM. – In recurrent cases in adults and in type 1 DM, removal of the nail spicule and partial surgical matrixectomy are used. – In recurrent cases in young patients, partial chemical matrixectomy using phenol or laser matrixectomy is possible. |
|---|---|
Stage IIa of infection (increased pain, edema, erythema, hyperesthesia, hemorrhage and/or infection; the nail fold extends beyond the nail plate and measures less than 3 mm) | Treatment: – In young patients and patients with controlled DM, removal of the nail spicule and partial surgical matrixectomy are performed; chemical matrixectomy using phenol is possible. – Topical treatment. |
Stage IIb of abscess (hypertrophy of the nail fold extends onto the nail plate and measures more than 3 mm) | Treatment: – Wedge resection of the nail plate and periungual fold according to the aesthetic reconstruction technique. – Partial surgical matrixectomy and chemical matrixectomy using phenol. – Topical treatment. |
Stage III of hypertrophy (granulation tissue or chronic hypertrophy of the periungual fold broadly encompassing the lateral or medial part of the nail plate) | Treatment: – Wedge resection of the nail plate and periungual fold according to the A. Winograd technique / Schmieden operation. – Topical treatment (multicomponent polyethylene glycol-based ointments with antibiotics, aqueous solutions, gels, and ointments with antiseptics). |
Stage IV of deformity (severe chronic deformity of the nail, both lateral periungual folds, and the distal fold. Hypertrophic tissue completely covers the lateral, medial, and distal parts of the nail plate) | Treatment: – In children and young patients with lateral, medial, and distal hypertrophy, wedge resection of the nail plate and periungual fold is performed according to the A. Winograd technique / Schmieden operation. – In adults, total matrixectomy using phenol is also an option. – Topical treatment (multicomponent polyethylene glycol-based ointments with antibiotics, aqueous solutions, gels, and ointments with antiseptics). |
Appendix C. Patient Information
What is an ingrown toenail?
An ingrown toenail is a condition where the edge of a toenail (and more rarely a fingernail) digs into the surrounding skin, causing inflammation or a wound.
Who gets ingrown toenails?
Anyone can develop them, but they most commonly affect adolescents, young adults, and older people. In teenagers, ingrown nails occur because feet tend to sweat more, which softens the skin and nails. In older adults, ingrown nails are caused by age-related nail changes and difficulties with nail care.
Nail ingrowth can also happen in people who try to "round off" the corners using a nail file or other manicure/pedicure tools. Injuries (such as stubbing a toe, running, or kicking objects) can also lead to this. Toenail ingrowth is sometimes hereditary and depends on the shape of the nail plate.
How do I know if I have an ingrown toenail?
You may experience pain or swelling. The skin around the toenail may also become red. As an ingrown toenail progresses, the pain and redness increase. Sometimes an infection develops. Bleeding or pus may appear. An ingrown toenail can also limit your daily activities, such as sports or walking.
What should I do?
In most cases, an ingrown toenail can be treated by washing the foot with warm water and soap and applying a sterile dressing with a topical antibiotic/antiseptic ointment. Your doctor may also place a cotton pad, kapolin, dental floss, or splints under the edge of the ingrown nail to separate the nail from the skin. Do not attempt to cut or remove the ingrown part of the nail yourself.
Tell your doctor if you are experiencing severe pain or think you might have an infection. You may need minor surgery to remove the ingrown part of the nail or the entire nail. Your doctor may also remove the nail bed to prevent the ingrown nail from returning.
Be sure to tell your doctor if you are pregnant, because some chemical agents used to remove the nail bed should not be used in pregnant or breastfeeding women.
It is critical to inform your doctor if you have diabetes mellitus or vascular disease, as this may affect treatment options.
How do I care for my toe after surgery?
During the first 5 days after surgery, you should observe bed rest with your foot elevated. If the toe is painful, you may be prescribed certain anti-inflammatory pain relievers (such as those containing ibuprofen or diclofenac). Dressings are required for two weeks after surgery. Tell your doctor if you still have pain, redness, or discharge from the wound. These are signs that the infection is progressing. In this case, you may need to take antibiotics.
How can I prevent an ingrown toenail?
First and foremost, it is important to maintain hygiene (wash feet regularly with soap), wear cotton socks, and shoes that fit properly. Trim the edges of the nail plate correctly or seek professional help, especially if you have diabetes mellitus or poor vision.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not applicable.