An ingrown toenail is a pain down the side of the toe caused by pressure from the ingrowth of the nail edge into the skin.  If the edge of the nail breaks through the skin, it may cause an infection.  Ingrown toenails most often occur in the big toenails on either side but can also affect the smaller toes.  Ingrown toenails are medically referred to as an onychocryptosis.

Mainly due to either the shape of the nail or the bulk of the flesh on the side of the nail.  Hereditary factors are usually to blame, where the nail plate can begin to curve over on the sides. Some people have very fleshy toes, so the nail lip will roll over the edge of the nail, causing irritation and discomfort.  Tight shoes are also an aggravating factor.  Damage to the nail root from shoes or injury will lead to thickening or deformity of the nail plate, which can become ingrown.  Improper trimming by cutting down the sides of the nails or picking and tearing the nails is also a problem, particularly in children and teenagers.

The warm, moist environment created by shoes and socks provides a perfect breeding ground for bacteria, fungi, and viruses. This is why once a nail starts to ingrow, it will commonly become infected. This causes soft tissue swelling and pushes even harder on the side of the toe, causing even more discomfort. For this reason, it’s wise not to ignore toenails once they become ingrown, as they rarely get better without treatment.

In the early stages, simply removing the nail portion and digging into the flesh can provide significant relief. Some people come back to a podiatrist every 6- 8 weeks to have their toenails trimmed, mainly if they are older and cannot get down to their feet. Saltwater soaks, and betadine are helpful if there is a minor infection. If the toe is badly infected and there is swelling of the soft tissue, a local anaesthetic may be required to numb the toe to remove the portion of the nail that is ingrown.  There is some minor discomfort in giving the local anaesthetic; however, this far outweighs the discomfort of trying to remove a painful nail edge.

Antibiotics help settle the infection, but the infection will usually reoccur once you finish the antibiotics because the underlying cause remains: the nail cutting into the flesh. It’s like having a wound with something still stuck in it. Healing will not occur until that piece has been removed.

After temporary removal of the nail edge, it is common to become ingrown again as the nail grows back.  Studies have shown that 70% of people with the nail edge removed temporarily will go on to have further infections. If the nail plate is not curved or the nail lip is not fleshy, it is possible to get the nail edge to grow out by packing cotton wool underneath the edge of the nail as it grows. This acts as a buffer to stop the nail from piercing or irritating the flesh and to encourage the nail plate to grow out over the top of the flesh.

People frequently have a false sense of security after removing the nail edge because the pain and infection have resolved. Because of the high recurrence rate, it is always a good idea to return after a procedure to remove an infected nail edge and check how the nail is growing back to see if you may require a permanent nail edge resection or to show you how to pack the nail with cotton wool as it grows. 

Permanent nail edge resection is a procedure where a small portion of the nail edge is removed, and a small incision of about 3 – 4mm is made over the nail root to surgically remove that portion so that the nail does not grow back on the side. 

If the side of the toe has excessive fleshiness, it is also remodelled. The flesh is then reattached to the edge of the nail using fine sutures. Sometimes, a bony prominence can be beneath the nail, contributing to the discomfort that may need removal. 

In most cases, we perform this procedure in our rooms. We can also do this in a hospital or day surgery under sedation or general anaesthesia, but this is rarely needed. We also use Penthrox (The Green Whistle) for patients worried about needles.

Another procedure involves removing the nail edge and cauterising the nail root using a chemical to stop it from growing back. This simple, easy-to-learn technique is popular with podiatrists and General Practitioners but is the only one they have learned how to do. Unfortunately, it is not appropriate in all cases and has several disadvantages. 

The chemical burn, if over-cauterized, can take a long time to heal. If the nail root is under-cauterised, it will allow the nail to grow back. It also does not address the overgrowth of flesh on the side of the toe, which is often the cause of ingrown toenails.  If a wide section of nail is removed, there is often a gap between the nail edge and the flesh, which cosmetically is not very pleasing and can be the cause of further irritation.

Surgical resection has a lower rate of regrowth and allows for remodelling of the fleshy nail lip. This means less nail needs to be removed, which gives a better cosmetic appearance.

We have general podiatrists and a podiatric surgeon who will use the technique best for your needs rather than only using the one we are skilled at.

In most situations, we remove just the nail edge.  Depending on the degree of deformity of the nail plate, in a small number of situations, we do need to remove the entire nail and nail root; however, we prefer to leave as much of the nail as possible to give a more normal cosmetic appearance.  Following total nail removal, hard skin forms over the remainder of the nail bed. This is quite normal and is not necessarily due to regrowth or partial regrowth of the nail.  If the whole nail is removed, some people will elect to have a false nail applied in the summertime if they wear sandals.

We use a long-acting local anesthetic so that you will feel no pain for 4- 6 hours afterwards. Everybody’s pain threshold is quite different, but most patients report a minor level of discomfort that is well controlled with Panadol and, Neurofen, or Panadine Forte. Rest and elevation for 24 hours also help a lot.

While it is not entirely without potential complications such as infection and regrowth, surgical resection of the nail edge has high success rates and patient satisfaction. We have refined the surgical technique so that there is less disruption to normal activity, better cosmetic results, and less likelihood of the ingrown toenail reoccurring.

You can walk immediately following the procedure, but you will be advised to rest and elevate for the first 24 hours to relieve discomfort. This is primarily because walking around too much can cause bleeding.

For the first three days, you will have quite a bulky dressing, which you must keep dry. This dressing provides some compression and minimises bleeding. It is generally changed within three days and replaced with a band-aid-type dressing. You can get your feet wet in the shower, provided the toe is dried afterwards, Betadine is applied, and a fresh dressing is used. We will give you the dressing that you will need to use.

We can only perform a permanent nail edge resection if there is no infection, so it is best to have a permanent procedure anywhere from 1 to 2 months after the temporary procedure has healed and the infection has resolved. For people who are working, most people choose a Friday to allow them the weekend to recuperate. If you play sport or have other commitments, it is best to allow at least 3-4 weeks before resuming sport.

This depends on what your work involves, what type of shoes you have to wear and how many toes or sides of toes are being operated on simultaneously. For example, somebody having a single nail edge removed in a desk job will not need any additional time off; however, if you were having multiple nail edges removed and your job requires you to be standing all day in an enclosed shoe, you would need a week or more off work. Shoes can put pressure on the toe, which can be a bit tender, and also create a warm, moist environment which is more likely to cause an infection, so you only wear enclosed shoes if you have to until the sutures have been removed in about 14 days after the surgery.

It is generally recommended that someone drive you home after the surgery, preferably until the first dressing change three days after the surgery. The bulk of the dressing can make it difficult to operate the pedals. 

Toenails have a relatively high risk of infection, mainly if there is a recent history of infection. If we have concerns about other medical conditions that may put you at risk of infection, we will put you on antibiotics during your surgery to reduce the likelihood of infection. We change the dressings on the third day following your surgery is to check for infection. You will need to monitor your toe daily after surgery until the sutures are removed and contact the rooms immediately if you have any concerns.

If you have a bad or long-standing infection on the side of your toe, this must be resolved before we consider removing the nail edge and root. Because the nail root goes down almost to the bone, attempting to remove the nail root simultaneously runs a high risk of spreading the infection.

For this reason, we will need to remove the nail portion in combination with antibiotics to allow the infection to resolve. This sometimes requires a simple procedure with local anaesthesia to remove the infected nail edge and, at a later stage, after the infection has settled, a second procedure to remove the nail root.

People are often afraid to consider ingrown toenail surgery because they hear it is excruciating, or they end up with an ugly, scared, disfigured toe. This has occurred with doctors or general podiatrists who only perform these procedures occasionally and don’t have specialist skills or training. This is one of the most common procedures performed by a Podiatric Surgeon with a high level of experience and expertise to give you the best option for achieving a good result.