Abstract
Introduction
Ingrown toenails are one of the common nail problems generally occurs in the big toe area and most often occurs during productive ages. Treatment of ingrowing toenail can be chosen based on the clinical condition of the patient. Nonoperative therapy is not effective in advanced cases in terms of the severity. Improper handling will cause recurrence in this case.
Case Presentation
Six of 8 patients had the ingrown toenail recurrence previously treated using the nail avulsion (onychectomy) without matricectomy. One patient was reported to have hemophilia as comorbidity. The other one had pincer nail associated with inflammatory and degenerative processes. Most patients were at modified Mozena grades III and IV ingrown toenail. Post therapy evaluation revealed no recurrence in all patients.
Conclusions
Combination of wedge resection with matricectomy using electrocautery can be applied as therapy for recurrent ingrown toenail.
Keywords: Ingrown, Nail, Matricectomy, Electrocautery
Established Facts
Nail avulsion with matricectomy decrease the recurrency rate of ingrown toenail. Nevertheless, none other superior methods reported and recurrences incidences related to patient's clinical condition.
Matricectomy in ingrown toenail cases could be done chemically with phenol liquid that has been reported in previous studies with low recurrences rate and good cosmetic results yet matricectomy procedure with phenol liquid has shortfall such as long procedure duration and presence of postoperative exudation.
Matricectomy in ingrown toenail cases with phenol liquid needs precise application to preserve and not to harm surrounding nail tissue. Thus, it needs longer duration to be done chemically.
Electrocautery could be used to achieve hemostasis of small blood vessels with shorter duration time. Wedge resection with matricectomy in the area of ingrown toenail procedure recruited involves many small blood vessels that could induce heavy bleeding.
Novel Insights
This case series reported all patients had nail avulsion procedure without matricectomy before and all had recurrence. We performed wedge resection procedure with matricectomy using an electrocautery device to prevent recurrence of ingrown toenail. In a 1-year follow-up, all patients reported good cosmetic results and no recurrence.
This case series reported good results of wedge resection with matricectomy using an electrocautery device with short recovery time of 1–2 weeks post-procedure compared to others case reports.
One of our patients reported in this case series had hemophilia and procedure performed with electrocautery device could be done in shorter duration of time with no bleeding complication reported.
Introduction
Ingrown toenails, also known as onychocryptosis or unguis incarnates, are one of the common nail problems with nails that grow inward [1, 2]. Study in South Korea showed that the prevalence of ingrown toenail was 0.5%, dominated by women, with exception, especially at the age under 30 years; the prevalence of ingrown toenail was dominated by men [3]. There are several factors that can cause ingrown toenail such as hyperhidrosis, nail deformities such as pincer nails, mechanical trauma such as improper nail cutting, uncomfortable shoes, comorbidities, and use of drugs such as epidermal growth factor receptor inhibitors [4]. Ingrowing toenail occurs when the lateral periungual nail fold experiences penetration trauma by the surrounding nail plate, causing an inflammatory reaction that can even cause infection if bacterial colonization occurs, which in the process will also form granulation tissue [5]. Such penetration is often caused by nail spicules at the edge of the nail plate, which triggers an inflammatory response due to an imbalance between nail plate width, nail bed, and nail fold hypertrophy [6, 7]. Improper management will lead to recurrence in ingrown toenail. Ingrowing toenail is classified according to the degree of severity based on Zaia and Modified Mozena by Martínez-Nova et al. (2007) who added stage IV to Mozena's classification system due to a progression of stage III presenting distal hypertrophy) [8, 9].
Treatment of ingrowing toenail can be chosen based on the clinical condition of the patient. Nonoperative therapy is not effective in advanced cases in terms of the severity according to Modified Mozena, and thus, operative therapy can be chosen as the main therapy. Several modalities options for treating ingrown toenail should also consider the presence of recurrence [10, 11]. The most common operative technique for hypertrophic nail folds is to remove the ingrowing nail and the surrounding nail fold by wedge resection. In this technique, matricectomy is also performed to damage the nail matrix on the affected nail bed [12].
Matricectomy can be done chemically or by electrocautery to prevent recurrence. Matricectomy with electrocautery was reported by Awad et al. in their study as an ablative procedure to destroy the nail matrix effectively, easily, and safely and to reduce postoperative pain. The study also reported a significant difference in postoperative wound healing and a low recurrence rate compared to other procedures, but this requires further comprehensive study [13]. We reported this case series in order to enhance reference on matricectomy using electrocautery in preventing ingrown toenail recurrence, along with other aspects such as safety, bleeding, postoperative pain, and infection.
Case Reports
The first, second, and third patients had Grade IV ingrown nail based on modified Mozena criteria (Fig. 1a-d, 2a-d, 3a, b). Modified Mozena grading is presented in Table 1. The fourth, fifth, and sixth patients were in grade III (Fig. 4a-d, 5a-d, 6a-d). All these patients experienced recurrence of ingrown nail and they had a history of nail avulsion before receiving wedge resection with the Winograd technique and electrocautery matricectomy. The seventh patient suffered from a grade III ingrown nail of medial digiti I sinistra and pyogenic granuloma with the comorbidity of Hemophilia Type A (Fig. 7a-f). This patient underwent wedge excision (Winograd) with electrocautery matricectomy and also a minor protocol for hemophilia with an intravenous bolus of Factor VIII 2500 IU injection at 2 h prior to procedure, during the procedure, and 12 h after the procedure. Post-procedure antibiotic therapy was given for 5 days based on the results of the pus culture and sensitivity tests. Three months after the procedures, erythema, lateral nail fold hypertrophy, edema, and maceration occurred on the lateral digiti 1 pedis I sinistra and medial digiti 1 pedis dextra. We then diagnosed him with ingrowing toenails of the lateral part of digiti I pedis sinistra and ingrown toenail of the medial part of digiti 1 pedis dextra (Grade III). Wedge excision (Winograd) with residual nail matrix curettage and hemophilia protocol was performed again. Matricectomy with electrocautery was also done to prevent recurrence. The eighth patient had a pincer nail (Fig. 8a-c) with Mozena grade IIa and widening of the base of left distal hallux bone observed on radiologic imaging. Electrocautery matricectomy and curettage were performed on the patient to prevent recurrence. The mentioned cases demonstrate ingrowing toenails in various patients' characteristics, Mozena criteria, and their recurrence. All cases were treated with wedge resection (Fig. 9a-f) combined with matricectomy using electrocautery to prevent recurrence (Fig. 10a-d) which is summarized in Table 2.
Fig. 1.
a Before wedge resection (Winogard technique) and electrocautery. b Seven days after surgery, the wound with surgical sutures appeared; there was no edema, erythema, pus and other signs of infection on both big toes. c Two weeks after the surgery and surgical suture removal; the surgical wound was completely dry. d Follow-up 1 year after the procedure; there was no recurrence, the nails grew normally, and there were no other complaints.
Fig. 2.
a Prior to surgery, regio digiti I pedis dextra showed lateral and medial ingrown toenail with hypertrophy, erythema, edema, and pus (+), and regio digiti I pedis sinistra showed lateral ingrown toenail with hypertrophy, erythema, edema, pus (+), granulation tissue (+), and crusting (+). b After surgery, there were no signs of infection, relatively mild postoperative pain, and controlled bleeding. c The results of evaluation carried out 3 weeks after the procedure showed improvement. d On 1 year evaluation, there was no recurrence.
Fig. 3.
a Regio digiti I pedis sinistra shows a medial ingrown toenail, accompanied by hypertrophy of the surrounding tissue, erythema, pus (+), and crusts (+). b 1-year postoperative evaluation; no complaints, no signs of recurrence.
Table 1.
Classification of severity of ingrown toenail and treatment modalities according to modified mozena [9, 10]
| Stage | Clinical symptoms | Therapeutic modalities | |
|---|---|---|---|
| I | Inflammatory stage: erythema, mild edema, tenderness on lateral nail fold compression, lateral nail fold not reaching the nail plate | General management Conservative technique In recurrent cases in the elderly with type I diabetes mellitus, excision of the spicules and partial matricectomy In recurrent cases in young patients, partial chemical matricectomy using phenol |
|
|
| |||
| IIa | Abscess stage: increasing pain, edema, hyperesthesia, oozing and/or infection, nail fold extended above the nail plate of <3 mm | In young patients and those with controlled diabetes mellitus, the partial chemical matricectomy using phenol | |
|
| |||
| IIb | Similar to stage IIa. Hypertrophic nail fold extends on the nail plate with the size of more than 3 mm | Resection of big toe wedge and nail fold with the esthetic reconstruction technique | |
|
| |||
| III | Hypertrophic stage: granulation tissue and chronic hypertrophy on nail fold, mostly cover the lateral nail plate | Wedge resection on nail and nail fold with Winograd technique | |
|
| |||
| IV | Hypertrophic distal stage: chronic and serious toe deformity of both distal and lateral nail folds. Hypertrophic tissue completely covers the lateral, medial, and distal nail plates | In young patients, nail resection and nail fold are performed using Winograd technique, while in adult patients using total matricectomy with phenol | |
Fig. 4.
a Before wedge resection (Winogard technique) and electrocautery. b After surgery. c Two weeks after surgery, the surgical wound was completely dry. d Follow-up 1 year after the surgery; no recurrence, normal nail growth, and no other complaints.
Fig. 5.
a In regio digiti I pedis sinistra' a lateral ingrown toenail appears with hypertrophy of the surrounding tissue, erythema, hyperpigmentation, edema, and crusting (+). b Postoperative evaluation showed no signs of infection, reduced pain. c Evaluation 3 weeks after surgery showed improvement, no signs of postoperative infection. d On postoperative evaluation after 1 year, the patient had no complaints, no signs of recurrence.
Fig. 6.
a Regio digiti I pedis sinistra shows a lateral ingrown toenail, with hypertrophy of the surrounding tissue, erythema, pus (+), and crusting (+). b Postoperative evaluation; no complaints, no signs of recurrence. c Evaluation 2 weeks after surgery; no signs of infection (d).
Fig. 7.
a Ingrowing toenail of digiti I pedis sinistra with medial periungual pyogenic granuloma. b Post-wedge excision procedure with minimal bleeding and good wound healing. c Condition improvement after the surgery. d The red circle mark indicates that the ingrown toenail occurs in the lateral part of digiti I pedis sinistra. e The medial part of digiti 1 pedis dextra. f After the second wedge excision on the lateral digiti I pedis sinistra and medial digiti 1 pedis dextra, bleeding was controlled and pain was relatively light. g Postoperative evaluation showed no recurrence, no postoperative infection, and good wound healing.
Fig. 8.
a In regio digiti I pedis sinistra, a medial pincher nail and ingrown toenail appear, accompanied by hypertrophy of the surrounding tissue and erythema. b Evaluation of the patient after the procedure. c Evaluation 4 weeks after surgery; no signs of infection. d Evaluation 1 year after surgery; no complaints and no recurrence.
Fig. 9.
a Wedge Resection Procedure with matricectomy using an electrocautery Anesthesia was performed using digital ring block technique. b Tourniquet was implemented on the big toe right on the nail matrix using a modified rubber and the surgical area was then marked on both lateral nail folds. c Wedge resection was performed on the nail fold experiencing hypertrophy and a part of nail plate, nail bed, and nail matrix was then removed. d terminating the nail matrix using an electrocautery on the lateral matrix ends. e, f suturing and giving a space for the nail growth, distal nail fold located under the nail plate.
Fig. 10.
Example of matricectomy implementation using an electrocautery. a Tissues appeared on the partially taken lateral nail fold, lateral nail plate, and lateral nail matrix. b, c Matricectomy was performed using a cauter. d Nail Spicule sticking on the taken tissue.
Table 2.
Characteristics and summary of the cases
| No | Sex and age (years) | Diagnosis | Risk factor/ comorbidity | Grading and therapy |
Complication |
Recurrency after treatment | |||
|---|---|---|---|---|---|---|---|---|---|
| modified mozena | therapy | pain | hemorrhage | infection | |||||
| Case 1 | F (16) | Recurrent ingrown toenail of digiti I dextra et sinistra medial et lateral | Improper nail cut hyperhidrosis | IV | Wedge resection + Matricectomy with Electrocautery | Minimum | Minimum | No | No |
|
| |||||||||
| Case 2 | F (25) | Recurrent ingrown toenail digiti pedis I bilateral | Improper nail cut | IV | Wedge resection + matricectomy with electrocautery | Minimum | Minimum | No | No |
|
| |||||||||
| Case 3 | F (24) | Recurrent ingrown toenail digiti pedis I sinistra medial | Improper nail cut | IV | Wedge resection + matricectomy with electrocautery | Minimum | Minimum | No | No |
|
| |||||||||
| Case 4 | M (28) | Recurrent ingrown toenail digiti I medial and lateral sinistra | Improper nail cut | III | Wedge resection + matricectomy with electrocautery | Minimum | Minimum | No | No |
|
| |||||||||
| Case 5 | F (28) | Recurrent ingrown toenail digiti pedis I lateral dextra | Hyperhidrosis | III | Wedge resection + matricectomy with electrocautery | Minimum | Minimum | No | No |
|
| |||||||||
| Case 6 | M (16) | Recurrent ingrown toenail digiti pedis I lateral sinistra | Improper nail cut hyperhidrosis | III | Wedge resection + matricectomy with electrocautery | Minimum | Minimum | No | No |
|
| |||||||||
| Case 7 | M (14) | Ingrowing toenail digiti I pedis lateral and medial sinistra and dextra, periungual pyogenic granuloma | - Hemophilia - Leg length discrepancy - Pyogenic granuloma |
III | Wedge resection + matricectomy with electrocautery | Minimum | Minimum | No | No |
|
| |||||||||
| Case 8 | F (59) | Pincer nail and ingrown toenail digiti I pedis medial sinistra | Osteoarthritis | IIa | Wedge resection + matricectomy with electrocautery | Minimum | Minimum | No | No |
Discussion
Ingrown toenail (unguis incarnatus) can affect on any age-group. This condition is generally (80% of the cases) unilateral and mostly affects the big toes [1, 14]. In this report, most patients (1st to 7th cases) are young adults with six female and 3 male patients with various risk factors. All patients experienced the ingrown nails on the big toe nails. Seven patients in this case presentation also had the habit of cutting the nails too curved. In 8th case, the patient was a 59-year-old woman whose nail have experienced shape changes (pincer nails) due to the degenerative and inflammatory processes (OA).
The ingrown toenail is surgically treated depending on the clinical severity, the failure of conservative therapy, and the presence of recurrence as the surgical therapy indications should be agreed by the patient [15]. Therapy decision on ingrown toenail should be based on clinical staging and severity of the cases. In this case series, Modified Mozena Grading was applied for classifying the ingrown toenail stage.
The presented 8 cases have different severity levels (Modified Mozena grade). In this serial cases, three cases were classified as Modified Mozena grade IV (1st, 2nd, and 3rd case) while 4 other cases (4th, 5th, 6th, 7th case) were classified as Modified Mozena Grade III. The management of these ingrown toenail cases included the wedge resection with the matricectomy using electrocautery for the nail matrix ablation. The surgical technique using the wedge resection is a common surgical option in ingrown toenail cases. This method was chosen because 6 of 8 cases were treated with nail avulsion and resulted in recurrences at different severity levels. Especially, for the 7th case with pyogenic granuloma and type A hemophilia, electrocautery has been considered to control and minimize the risk of bleeding. The 8th case was classified as Mozena Grade IIa with pincer nail that invaded on nail fold tissues resulting uncomfortable sensation and pain. Thus, the same methods as 7 previous cases were performed to anticipate the recurrence on the growth of the abnormal nails of the 8th case. The education and agreement of patients are greatly required to explain the associated risks and improve the patients' life quality.
In some literatures, the recovered ingrown toenail cases were said incomplete and the recurrence still possibly occurred, yet several different surgical techniques were provided for the best results based on the clinical stage (Modified Mozena) [7]. The ingrown toenail surgical procedures included nail plate, nail bed (germinal matrix), and the surrounding soft tissues. The recurrence rate after surgery on the partial nail extraction without matricectomy possibly caused the increasing recurrence rate up to 73–83% [14]. The recent studies have reported that with the matricectomy technique, the recurrence rate decreased up to less than 5%, with the wedge nail resection technique combined with the various matricectomy techniques [1, 7].
This type of surgery can provide a high recovery rate. In 1st, 2nd, 3rd, and 4th cases, wedge resection surgery was indicated due to the chronic deformity in pedis digiti area I and the surrounding tissues which were on the lateral and distal nail fold sides, so that the hypertrophic tissue completely covers the lateral area as well as the medial and distal nail plate (Modified Mozena Grade IV), while in cases 5th, 6th, and 7th cases, the granulation tissue and chronic hypertrophy of nail fold were formed covering the lateral nail plate (Mozena Grade III). All of these cases previously had the nail avulsions and recurrences, so that wedge resection was considered with a combination matricectomy to prevent from recurrence.
Wedge resection could cause severe pain due to the surgical wound in the periosteum area caused by the nail matrix surgery. In these cases, the patients were educated with the treatments and administration of antibiotics and painkillers after the procedures to prevent from the postsurgical infection. In the 7th case, the patients had the comorbidity related to a blood disorder in the form of hemophilia possibly inhibiting the wound healing processes. The patients also had the ingrown toenail infection in the form of pyogenic granuloma, so that the administered antibiotics were in accordance with the culture results and sensitivity tests.
Matricectomy is a nail matrix damaging technique to prevent the nail from growing back permanently [16]. Matricectomy can be performed using various techniques: chemically with phenol, sodium hydroxide, trichloroacetic acid, damaging matrix physically using the CO2 ablative laser, cryotherapy, radiosurgery, electrocautery, and curettage [15, 16]. Electrosurgery was one of the methods to treat ingrown nail that used high energy, while electrocautery only used a small electrical current utilizing the metal wires applied to the target tissue to burn or coagulate a specific tissue area and was then damaged. Electrocautery is a relatively safe procedure since the electrical energy does not flow through the patient's body, yet only affects the target tissue [17, 18].
In this case series, electrocautery has been performed and chosen rather than electrodessication or electrofulguration because electrocautery is more appropriate for nonconductive tissues like nail, bone, and cartilage. This procedure does not involve the patient's body as circuit loop and the heat is transferred locally to the targeted tissue, i.e., nail matrix. Although electrodessication or electrofulguration is safe for patients without contraindications, electrocautery was chosen to destruct the nail matrix through the heat which runs in filament in order to produce protein denaturation and prevent the recurrence. In addition, electrocautery is widely available device in developing countries. Thus, it can be considered to be applied for matricectomy aside from chemical matricectomy. It has been reported that the effectivity of matricectomy using various modalities is comparable, which is basically it has similar goal that is reducing the recurrence [11, 19].
In these cases, the wound presented after the surgery got better in 1-2 weeks and was continuously improved in 4 weeks with a relatively minimum pain. The evaluation made to all cases within a year after the surgery shows that there was no recurrence and infection after the wedge resection combined with matricectomy using electrocautery.
The matricectomy principle using electrocautery has the same objective with the other techniques, i.e., damaging the nail matrix on the ingrown toenails to prevent from the recurrence. A report compared the matricectomy with phenol and electrocautery. Both were equally effective in suppressing the recurrence by preventing the nail to grow once again in the areas experiencing the ingrown toenail [18]. Wedge resection with matricectomy in the digital area involved many blood vessels, so that the bleeding caused by this procedure was adequately large, especially in patients with the comorbidity of clotting disorder [20, 21]. In these serial cases, the wedge resection with a combination of matricectomy using electrocautery was selected based on its safety. In 7th case, the patients with the comorbidity of hemophilia had the surgical treatment management based on the hemophilia protocol to prevent from the severe bleeding. The matricectomy using electrocautery was also chosen to control bleeding during and after the surgery. The bleeding experienced by those patients was well controlled.
Some literatures reported that there is no significant difference between the results of matricectomy with electrocautery, phenol, and cryotherapy in the esthetical term. The ingrown toenail patients treated with these procedures had an adequately high satisfaction level in the aesthetical term with the minimal postsurgical wound [17, 18, 19]. In this report, patients did not complain related to any aesthetic disturbance either related to the big toe nail growth or shape after surgery. The evaluation made for 12 months showed that there was no recurrence in all patients.
Conclusion
Matricectomy with combination of electrocautery could be considered as surgery approachment in recurrent ingrown toenail cases to prevent recurrence with controlled bleeding and minimal risk of infection.
Statements of Ethics
Ethics Committee of Dr. Moewardi General Hospital decided this study was not required ethics approval. Written informed consent was obtained from the adult patients and from the parent/legal guardian of the child patient for publication of the details of their medical case and any accompanying images.
Conflict of Interest Statement
No potential conflict of interest was reported by the author(s).
Funding Sources
No funding aid involved within the process of study and publication.
Author Contributions
Nugrohoaji Dharmawan contributes to case findings and literature studies; Putri Oktriana Rachman and Adniana Nareswari contributes in article writing; Ummi Rinandari, Achmad Fiqri, and Eka Devinta have roles in editing manuscript, literature studies, and documentation of study
Data Availability Statement
All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.
Funding Statement
No funding aid involved within the process of study and publication.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.