Bathroom Surgery: not doctor approved for an ingrown toenail

One of the most common procedures I perform in the clinic is removal of an ingrown toenail. I'll come clean and admit that I once tried to treat one of these on myself (before college, med school, etc.) and had to admit defeat and go to a specialist to have it treated surgically. An ingrown toenail is very annoying, nagging, and seems so simple to fix to the untrained eye. With that in mind, it's not a huge surprise that people will attempt to treat these themselves because of the factors I've just listed.

Most of the patients I see who have ingrown toenails have at some point performed some sort of procedure on themselves in an attempt to alleviate their pain. This is very painful and often makes the problem worse, so people end up more inflamed or infected than they would have been before coming in to me. There are also a lot of myths about ingrown toenails that people think might help, so I'm going to address some of those today.

What is an ingrown toenail?

An ingrown toenail is where the edge of a nail has begun to dig into the skin next to it. This can happen with a split in the nail because of injury, tight-fitting shoes, or just plain bad luck. The long and the short of it is that this condition is caused by lots of factors, most of which you have very little control over. A common theme in foot problems is that genetics play a big role in their development; ingrown toenails are no different. There are a number of physical attributes about your toes that are inherited, much like your eye or hair color is. Ever have a person tell you that you look just like a parent or grandparent? Well, the same could be said of your feet--not that people should take photos of each others' feet for posterity's sake, but if you did, you'd probably find a striking resemblance in the shape of the nail, the pudginess of the flesh around the nail, how much the toe nudges up against the neighboring toes, etc. to that of your parents or grandparents.

But my nail doesn't look ingrown!

You'd be surprised how much of your nail actually grows beneath the surface of the skin. Even in a normal nail, there's a ton of nail beneath the skin edges, but it isn't caught up in the flesh and successfully exits the nail bed without taking skin with it.

With an ingrown nail, the nail runs into the skin on the edge of the nail and fails to exit. There's usually a larger amount of nail that is covered by the skin.

There are some conservative treatments you can try at home to prevent an ingrown toenail from worsening or developing before you are forced to throw in the towel and come to a specialist for removal. Keep in mind that none of these methods are 100% effective, and you're probably looking at a 50-50 shot of any of these working, but if you're naturally terrified of procedures, or you YouTubed horrific nail procedures which have made you petrified of coming to see me these are some methods to try and stave off certain death (or ingrown toenail surgery).

What Not to Do

The biggest myth I've heard people try is that cutting a notch in the middle of the nail will somehow pull the nail away from the edge of the skin, allowing it to stop growing in. This just doesn't work, and may actually make the nail easier to injure in the future. Just don't do it. End of story.

The next myth is that cutting square edges will solve your problem. This is better than the above technique, but may cause the nails to be easier to split on the edges, leading to ingrown nails.

Manual Retraction

The first thing I recommend for prevention of an ingrown nail is using your fingers to try and pull the skin edges away from the nail edge, so the nail can be pulled out of the flesh and be allowed to grow free of the skin. Another technique along the same lines is using some sort of really sticky tape (scotch, electrical, duct tape, etc.) to tape along the affected edge, then pull it under the toe and tape it to the underside of the toe to maintain a similar type of retraction throughout the day.

You can also try putting a small amount of cotton ball wadded up beneath the affected corner of the nail. While not 100% effective, these will give you a better shot at avoiding a procedure.

Treat the Local Infection/Inflammation

Usually an ingrown toenail causes inflamed tissue, which is more likely to develop an infection. Epsom salt soaks help to relieve inflammation and may help stave off infection. Using a topical antibiotic like triple antibiotic ointment or bacitracin will help with infection control for mild ingrown toenails.

In order to fix an ingrown, you often have to remove the edge of the nail that is growing into the skin. Sometimes a temporary removal will help get rid of any infection or inflammation and then allow it to grow back uneventfully, but it will often go back down the same road it did that got you into this situation to begin with because your genes haven't magically changed, neither has the inherited nail shape, so without changing something, it will come back.

What Does Treatment Involve?

Usually, if you're developing an ingrown toenail right now, you'll probably develop one in the future if you only have a temporary treatment performed. Some conservative approaches can work on occasion, such as an angled cut of the offending nail edge, combined with the manual retraction techniques can help, but in my experience it is often kicking a problem down the road a short ways before dealing with it again. Because of this, I recommend typically a permanent removal of the offending nail edge, so it doesn't come back. 

It's at this stage that I recommend you avoid any online videos of ingrown toenail procedures because it only stresses out the person who might need this done--enough to even prevent people who really have badly infected nails from getting necessary medical treatment. Honestly, I have had a number of people just this month who put off having a necessary nail surgery because they had freaked themselves out about it by watching videos online. Once they had calmed their nerves (and the pain was too great) they called and scheduled with me only to find that the procedure was MUCH better than they had imagined it being.

Below is some advice for you once you decide to have the procedure done. If you decided to come into my office, it was very good to meet you! If you haven't had this done yet, it's still good information to know.

How Bad is My Recovery Going to Be?

Typically, recovering from an ingrown toenail procedure is fairly straightforward. It usually involves soaking in a solution of epsom salt (sometimes with added antibiotic powders) twice a day and applying antibiotic ointment and an adhesive bandage for protection. Usually patients are numb in the affected toe for a few hours, so I recommend taking an over the counter pain medication about 2 hours afterward, so you're ahead of any post-op soreness before the local anesthetic wears off. I have people continue this for about 3-4 days, which is usually when the soreness starts to fade. 

I also recommend taking it easy for a few days, because being on your feet causes swelling, which causes throbbing and soreness in the toe. My advice after one of these: take it easy and just relax as often as you can. It's not going to be torture to recover from, but it's not like a spa treatment.

I really only have a few hard-set rules about what you can and can't do after an ingrown toenail procedure, and they all revolve around water and the increased risk of infection afterwards when exposed to public water sources. Basically the rule is: no pools, no hot tubs, no swimming in a lake or river. Those areas are cesspools of bacteria, so until your skin (your body's natural barrier against infection) is fully healed up you should minimize your infection risk by staying away from these infection-prone areas.

How Do I Know if My Toe is Infected?

Typically, risk of infection after a procedure like this is pretty low, but on occasion I've had patients who developed a mild infection in the operative site. Rarely a patient will have regrowth of the nail, even when the procedure has gone smoothly. So what do I need to know about an infection?

Everyone--no, EVERYONE--develops redness after these procedures. That's part of your body's healing process--this particular stage is called the inflammatory stage. Inflammation leads to the increase of blood flow to the area, bringing with it healing nutrients and worker cells that rebuild damaged tissues. This makes the toe look red, which often is mistaken for infection.

Usually an infected toe has redness that doesn't blanch. That means that when you press on the red area, it will still be red when you release your pressure. Normal inflammation goes white when you press and release, with a slow return of the normal pink inflammation. Unless the redness remains unchanged, you're typically dealing with the normal healing process.

Another clue is drainage. Everyone has a small amount of drainage from the procedure. Injured tissue leaks a little bit until healed. A small amount of clear drainage is normal. What you don't want is what looks like the dairy section coming out of the nail edge. If your drainage looks like yogurt, milk, or cottage cheese we should talk about getting you an antibiotic. 

Summary

Ingrown toenails are annoying, painful, and often lead to a small nail procedure to resolve. If you have them, you can thank your parents (one or both of whom have dealt with them as well). There are some things you can try on your own to remedy them, but usually they require a procedure to fully resolve. Don't watch videos online of it, it'll just freak you out. Neither the procedure nor the recovery are really that bad, and most people do fine as long as they avoid going to the public hot tub afterward. In the end, though, nobody is going to make you get the nail taken care of (unless you're a minor and your parents make you, in which case I'm sorry but it's for your own good ;-).

As always, the diagrams are mine. Not that they're a ton to be proud of, but they did take a few min to make.