Ingrown Toenail (Onychocryptosis): Stages, Surgery and Recovery

What happens in an ingrown toenail

The nail plate grows forward from the matrix under the cuticle. Its side edges sit in grooves (the lateral nail folds). If the edge is cut short, curves down, or is squeezed by a shoe, a sharp corner or spike pierces the skin of the fold as the nail grows. The body reacts to the nail as a foreign body: the skin swells, which traps the nail further, and bacteria enter the break in the skin.

It is common in teenagers and young adults, especially athletes, and in older adults with thick or curved nails. The big toe is involved in the vast majority of cases. For a general overview including fingernails, see ingrown nail.

Ingrown toenail stages

A pincer or "trumpet" nail, where both edges curl down sharply, is a related problem that often needs both edges treated.

Causes and risk factors

• Trimming errors: cutting the nail too short or rounding the corners, so the skin folds over the edge
• Tight or pointed shoes, high heels and tight socks
• Nail shape: a naturally wide or strongly curved nail, often inherited
• Sweaty feet that soften the skin, common in teens
• Trauma: stubbing, a dropped object, or repeated pressure from running and kicking sports
• Toe position: bunions or toes pressing against each other (toe deformities)
• Thickened nails from fungal infection or age

Home care for early (stage 1) ingrown toenails

• Soak the foot in warm water for 10 to 20 minutes, 2 to 3 times a day.
• After soaking, gently lift the corner of the nail and place a small wisp of clean cotton or dental floss under it. Change it daily. This guides the nail over the skin as it grows.
• Apply petroleum jelly and a bandage.
• Wear open-toed or roomy shoes.
• Take acetaminophen (paracetamol) or ibuprofen at the label dose for pain.

Do not dig out the nail corner or cut a "V" in the middle of the nail. These do not work and can make it worse. If there is no improvement within 3 to 5 days, or pus develops, see a clinician.

Ingrown toenail surgery: partial nail avulsion

A partial nail avulsion is a short, office-based procedure done by a podiatrist, family doctor or dermatologist.

What happens

1. Numbing: a local anesthetic injection at the base of the toe (a digital block). This is the only painful part, and the toe is then fully numb.
2. A tourniquet around the toe keeps the area bloodless.
3. Removal: a narrow strip of the nail edge, typically a few millimeters wide, is freed and pulled out from tip to root.
4. Matrixectomy: to stop that strip regrowing, the nail root under it is destroyed, most often by applying phenol for about 1 to 3 minutes. Alternatives are sodium hydroxide, electrocautery, laser or surgical excision.
5. Dressing: an antibiotic ointment and bulky bandage.

The whole procedure takes about 15 to 30 minutes. A total nail avulsion is reserved for severe or repeated problems affecting the whole nail.

Does it work?

Partial avulsion with phenol is the best-studied treatment. Cochrane reviews show it is far more effective at preventing recurrence than simple nail removal without matrix treatment. Recurrence after phenol matrixectomy is typically under 10%, compared with much higher rates when the nail edge is removed without treating the root.

Recovery and aftercare

• Day of surgery: rest with the foot raised. Throbbing starts as the anesthetic wears off after a few hours. Use acetaminophen or ibuprofen at the label dose.
• Next day: remove the dressing and begin daily warm salt-water or soapy soaks, then apply ointment and a fresh bandage.
• Drainage: after phenol, a yellowish weeping discharge is normal for 2 to 4 weeks. It is a chemical burn healing, not necessarily infection.
• Shoes: wear open or loose shoes for 1 to 2 weeks.
• Activity: most people return to work or school the next day. Avoid running, kicking sports and swimming for about 2 weeks.
• Healing: usually complete in 2 to 6 weeks. The nail will be slightly narrower but looks normal to most people.

Contact your clinician if you get increasing pain, spreading redness, red streaks or fever after the procedure.

Antibiotics

Studies show that antibiotics before or after nail surgery do not speed healing or reduce recurrence in otherwise healthy people. They are used when infection is spreading into the toe or foot (cellulitis) or in people at high risk.

Ingrown toenails with diabetes or poor circulation

Do not treat ingrown toenails yourself if you have diabetes with numb feet, peripheral artery disease or a weakened immune system. Small wounds can quickly become deep infections. See a podiatrist early. Phenol is used cautiously when blood flow is poor, and healing may be slower. See diabetic foot problems.

Preventing recurrence

• Cut toenails straight across, leaving the corners visible just beyond the skin. Do not round them or cut them very short.
• Cut after a bath, when nails are softer, using straight-edged clippers.
• Choose shoes with a deep, wide toe box, and socks that are not tight.
• Wear protective footwear for kicking sports and work.
• Keep feet dry and treat fungal nails, which thicken and distort the nail.
• If one side keeps coming back, ask about a permanent partial matrixectomy rather than repeated temporary fixes.

Frequently asked questions

What is onychocryptosis?

Onychocryptosis is the medical term for an ingrown toenail. It comes from Greek words meaning "hidden nail", because the edge of the nail becomes buried in the skin fold beside it. It usually affects the big toe and causes pain, redness, swelling and sometimes infection.

How long does it take to recover from ingrown toenail surgery?

Most people walk out of the office and return to work or school the next day. Wear loose shoes for 1 to 2 weeks and avoid sport for about 2 weeks. The wound usually heals fully in 2 to 6 weeks, with some weeping for the first few weeks after phenol.

Why does my ingrown toenail keep coming back?

The usual reasons are cutting the nail short or curved, tight shoes, and a naturally wide or curved nail. If the nail edge is removed without treating the root, it regrows the same way. A partial nail avulsion with phenol matrixectomy permanently narrows the nail and prevents most recurrences.

Is ingrown toenail removal painful?

The numbing injection stings for a short time, but the procedure itself should be painless. Afterwards there is usually throbbing for a day or two, which over-the-counter pain relievers control. Most people say it hurts much less than the ingrown nail did.

Can an ingrown toenail heal on its own?

A mild stage 1 ingrown toenail often settles with soaks, lifting the edge with cotton or floss, and roomy shoes, as the nail grows out over the skin. Infected or overgrown ones rarely resolve fully without treatment and tend to recur.