Recent article concludes simple wedge resection for ingrown toenail leads to nail bed damage and unacceptable recurrence rates – and should be considered obsolete.
Dermatol Res Pract. 2012;2012:783924. Epub 2012 May 20.
Controversies in the treatment of ingrown nails.
Haneke E. free article here
- Article is an exhaustive review of various techniques used.
- Concluded that wedge resection alone can lead to nail damage and unacceptable recurrence.
- In article itself he omitted clear reference to statistics on that.
- I wrote him and he had some helpful insights:
– authors do not like to write about their recurrence rates. I can sort of see why – these authors are often in tertiary care centres where they get the worst of the worst.
– One reference he did supply was a large study on children:
Ann R Coll Surg Engl. 2011 Mar;93(2):99-102. Epub 2010 Nov 12.
Surgical treatment of ingrown toenails in children: what is best practice?
Mitchell S, Jackson CR, Wilson-Storey D free article here
– wedge resection alone – 87/180 recurrence with re-operation – almost 50%
– wedge resection with phenolization nailbed – 73/344 = 21% recurrence difference by my chi-square is p<0.001 - His conclusion was: – phenolization is simple, less painful, safe even in diabetics and vascularly compromised, and has lower recurrence rates and healing times than the alternative.
Technique: – the wedge resection pre-phenolization has been described here:
Ingrown Toenail Removal
THOMAS J. ZUBER, M.D.
Am Fam Physician. 2002 Jun 15;65(12):2547-2550. free article here
One article with good results was:
Dermatol Surg. 2010 Oct;36(10):1568-71.
Digital block with and without epinephrine during chemical matricectomy with phenol.
Altinyazar HC, Demirel CB, Koca R, Hosnuter M. abstract here
- Using 2% lidocaine with 1:100,000 epinephrine gave the best results – 1 ml applied to each side and repeated in 5 minutes as necessary.- I have been applying tourniquet first and then doing ring block using 2% plain. Their technique would be less damaging and they claim faster healing rates.
- apply tourniquet after – I have patient lie on abdomen with knee bending leg up to drain it some before applying.
- trim off 2-3 mm of lateral nail – and only amateurs cut the cuticle in process…
- Curette out granulation tissue
- Partially strip 3 cotton applicator and saturate with concentrated 88% phenol.
- (At this stage I put lubricant gel over the adjacent to nailfold skin areas I do not want phenolized)
- Apply to nail matrix and vigorously massage it in – change twice during the application (one study with 1, 2, and 3 minutes had a recurrence rate of 12.9, 3.9, and 2.1% respectively – so 2.5 minutes sounds good to me…). First author does bilateral wedge resections and this might be wise for deformed or thickened nails particularly.
- lavaged with 70% isopropyl alcohol – since my table is close to the sink and at table level, I just have patient put foot in sink and run water over it – I could see how alcohol would be better as phenol is not water soluble. (maybe syringe initially with alcohol and then run water?) addendum – I now have them put foot in a pail and douse with fluids
- Remove tourniquet – I have that done with on tummy with knee bent up position again to limit bleeding. It has also been suggested 20% ferric chloride application could reduce bleeing and heal time (to make up – used as an etchant in electronics – get bottle, dilute to 20 % and autoclave – note – pull out plug when autoclave finishing so not get violent reduction of air pressure with boiling)
- Apply antibiotic ointment
- Gauze wrap
- They used povidine-iodine soaks 15 min daily followed by topical antibioitic and I could see this for diabetic or worrisome cases.
Comment – with 2% lidocaine and epinephrine – drainage only 11 days versus 19 days without epineprine. – not sure would use in any diabetic or vascular compromised cases though…
Any technique suggestions?
It has been awhile since I bothered doing phenol nailbed destruction and there are some technical points that have come back to me now:
1) There should be no contention that deformed (eg. – U shaped nails) and thickened nails need phenolization.
2) Phenol stinks so do it in a well ventilated room that you don’t need to use right away and can air out.
3) Protecting normal skin areas with gel is helpful.
4) You have to get the swab to just the right wetness or it will drip around the toe.
5) Make sure you can see your watch while doing phenolization.
6) Soak all 3 swabs ahead of time – though will really stink up room – because of time constraints
7) An ordinary scissors may not cut it…
8) Use 2% lidocaine and be prepared to repeat shot in 5 minutes – so will need 10 minutes prep time.
9) As anyone who has done molluscum contagiosum with phenol will tell you – phenol makes it bleed more – enjoy…
10) Rinsing with 70% isopropyl alcohol works and then water rinse over sink will work – the latter can get bloody so have towels ready…
Found that podiatrists are charging 2.5 times what I get for doing it – the joys of socialized medicine.
From Admin:
Some points from experience:
1) I have patient move down a table and put foot under sink to rinse out phenol after. I have to make sure table is close enough to sink and I now have patient try to move down ahead of time just to see they can do it…
2) swabs used for phenol are soaked ahead of time and squeezed out so not too watery…
3) People with U shaped pinching in nails need to have phenolization done on both sides or they will be back…
4) I protect the normal skin with KY-gel like lub – might have to reapply as go along.
-admin