Conservative treatment of ingrowing toenails

Abstract

We read with interest the article 'Conservative treatment of ingrowing toenails' by Reijnen and Cons (Br J Surg 1989; 76: 955-7). We acknowledge that a period of conservative treatment should be considered before surgical intervention; yet is it necessary for patients to endure such prolonged suffering for very little reward?The absence of an alternative treatment group, such as simple nail edge packing or gutter insertion and the heterogeneous nature of the patient population combine to make this a poorly designed study. Eleven doctors undertook conservative treatment on only an average of I 1 nails but each individual's performance is not specified. The authors claim that their treatment is 'time consuming' but fail to report how long each primary treatment took. As patients were not reviewed independently, an unbiased, objective assessment cannot be made. The results of conservative management in the 30 patients who had previously undergone toenail surgery, and therefore demonstrated resistance to previous treatments, have been omitted.The 'conservative' technique in itself appears to border on the barbaric. Analgesia requirements and the amount of pain suffered by each patient during this procedure are not stated. We suspect that lifting embedded nail edges out of the nail fold and filling the central portion of an ingrowing nail would be extremely distressing for the majority of patients if no analgesia was administered. Furthermore, 31 nails (26 per cent) ruptured as a result of filing. This morbidity is excessive and unacceptable.Nail edge excision and phenolization under digital block anaesthesia in our experience can be completed in 15min and has a recurrence rate of i 1 0 per cent at one-year review'. The cosmetic results are satisfactory and the treatment is not attended by the complication of nail rupture.Reijnen and Goris' proposed technique has not been shown to be superior to conventional methods of conservative treatment and cannot be justified in ingrowing toenail management. Authors' reply SirWe would like to comment on the remarks of Mr J. H. Anderson et al. point by point. Our study was started because the literature furnishes little information on the conservative treatment of ingrown toenails. The aim was to establish the value of this specific approach in different stages of ingrown toenail. We did not intend to prove its superiority to another method. Our study clarifies that by using this initial approach an important proportion of patients is cured completely. We do not consider a 94 per cent cure rate after 1 month, nor an 84 per cent cure rate after 1 year in stage I and I1 ingrown toenail 'very little reward'. We recommend a conservative approach for stage I and I1 only.We consider it an advantage of our study that this success was achieved by 1 1 doctors following a fixed protocol. It reflects the practical value of this approach.In our opinion the number of (check) visits justifies the use of the term 'time consuming' although primary treatment takes up to 15 min, at its maximum.We...

A systematic review and meta‐analysis of randomised controlled trials on surgical treatments for ingrown toenails part I: recurrence and relief of symptoms

“…Ahsan (2019) [27] No definition provided Akkus (2018) [28] No definition provided AlGhamdi (2014) [29] No definition provided Altinyazar (2010) [30] Recurrence was defined as occurrence of any clinical sign of regrowth of the treated nail edge, such as pain, discomfort, erythema, or drainage. Spicule formation, which shows the inadequate destruction of the germinal matrix, was also accepted as recurrence Alvarez-Jimenez (2011) [31] Recurrence rate was evaluated as growth of the released nail (or of a piece of the released nail) even though that recurrent nail might be asymptomatic Anderson (1990) [32] Exley et al Journal of Foot and Research (2023) 16:35 [39] called their procedure 'Nail edge excision' the procedure described was the same as partial avulsion.…”

A systematic review and meta‐analysis of randomised controlled trials of surgical treatments for ingrown toenails part II: healing time, post‐operative complications, pain, and participant satisfaction

“…It was also often unclear which outcome had been collected at which timepoint, and measurement techniques were often unclear or poorly reported. Of the 20 studies, only 2 studies [33, 36] mention the use of bacterial cultures to identify infective organisms and 2 studies [25, 44] reported measuring post‐operative bleeding using a scale of mild, moderate or abundant on assessment of the dressing.…”

“…These criteria were absence of exudate at gauze; formation of scab covering the wound; the wound must be kept uncovered; no signs of infection or inflammation at nail folds; no signs of erythema or hypergranulation tissue Reyzelman (2000) [26] Healing time was defined as the interval between the day the phenol matrixectomy was performed and the resolution of drainage and inflammatory changes surrounding the nail border. In every case, healing was identified by the principal investigator of the trial Tatlican (2009) [27] Complete healing was defined as the complete reepithelialization of the nail bed and the cessation of drainage Van der Ham (1990) [28] No definition provided Varma (1983) The average time to become pain-free was 3.6 days, with no statistical difference between the groups studied Andre (2018) [33] A and applied to nail surgery [54][55][56]. Despite the clear interest in post operative infection as an outcome, only one trial explored the use of oral antibiotics and found no evidence that they reduced the rate of post operative infection.…”

“…Twenty studies [20,21,23,[25][26][27][32][33][34][35][36][37][38][39][40][41][42][43][44][45] (Table 3) assessed the post-operative complications of infection and/or haemorrhage. Follow-up times varied across the studies, ranging from just 48 h for haemorrhage [32], to 3 to 5 days for infection [45] and some up to 6 months [42] and beyond.…”

“…Surgical matrixectomy v' s Surgical + chemical matrixectomy (n = 1 study)Anderson (1990) [32] A: Nail bed excision (n Surgical matrixectomy v' s 'Other' (e.g., laser and electrocautery) (n = 2 studies) Kim (2015) [44] 1%) occurrences Exley et al Journal of Foot and Ankle Research (2023) 16:55…”