Steri-Strip Sling Technique – A Simple Procedure for the Management of Ingrown Toenails – A Prospective Study

Abstract

Background:

Ingrown toenail is a nail disorder that commonly affects great toenails. Surgical modalities are commonly used as first-line treatment. A conservative approach is preferable as surgical procedures lead to pain and affect routine activities. Our aim is to study the efficacy of a new conservative technique using steri-strip^TM for the treatment of mild to moderate ingrown toenails as an outpatient procedure.

Methods:

Fifty patients presenting with stage 1–2 ingrown toenails were treated with the ‘steri-strip sling technique’. Steri-strip^TM is inserted between the disto-lateral edge of the nail plate and nail fold and secured with an elastic bandage. The dressing is kept till the nail edge grows over the nail fold and stops penetrating the skin. Patients were reviewed every week for a month after the treatment and monthly thereafter. The final result was assessed at 6 months. The success of treatment was assessed clinically and by patient satisfaction levels.

Results:

Fifty patients were treated and followed up. Immediately after the procedure, all patients reported significant relief in pain. After 6 months, 46 out of 50 patients were satisfied with the treatment and showed no recurrence. No complications were reported.

Conclusion:

The ‘Steri-strip^TM sling technique’ is a simple and effective outpatient procedure for the management of mild to moderate ingrown toenails.

Introduction

Onychocryptosis or ingrown toenails is a common nail disorder that frequently affects the great toenails.[1] It occurs when the lateral nail fold is penetrated by a spicule of nail at the edge of the nail plate leading to pain, inflammation and formation of granulation tissue.[2] Main predisposing factors include poorly fitting shoes and incorrect nail trimming techniques. Proper trimming technique allows the corner of the nail to project beyond the edge of the skin. The toenails should be cut straight across, instead of rounded at the edges.[3] Cutting the nail too short allows bulging of soft tissue leading to inflammatory reaction and pressure necrosis.[4] Patients initially complain of pain followed by redness and swelling; which may lead to infection, discharge and formation of granulation tissue.[1] There are various treatment modalities depending on the stage and severity but it is preferable to treat at an earlier stage when the patient complains of pain and redness.

The present study was conducted to assess the efficacy of a conservative technique for the treatment of ingrowing toenails as a simple outpatient procedure.

Methods

A prospective study was conducted after informed patient consent and institutional ethical clearance at the dermatology department of a tertiary care centre. All consecutive patients of either gender presenting with stage 1 or 2 ingrown toenails were included. Patients with stage 3 or 4 ingrown toenails with hypertrophic nail fold or granulation tissue, other nail disorders due to psoriasis, chronic eczema, lichen planus, subungual haematoma were excluded, as were those who did not consent to treatment or follow-up, had a systemic illness like hypertension or diabetes mellitus.

Sample size was estimation

The prevalence of ingrown toenails has been reported to be ~3%. Considering a 95% confidence interval of proportion and margin of error of 5%, the sample size was calculated as:

n = [(z)² (p) (q)]/(d)².

n is the sample size, and z is the value for the selected alpha level, that is 1.96 for 95% confidence level, P is the estimated prevalence of attribute that is present in the population, q is 1-P, d is the acceptable margin of error for the proportion being estimated (taken as 5%).

n = [(1.96 × 1.96) x (0.03 × 0.97)]/(0.05 × 0.05) = 44.7–45.

For possible dropouts, 50 patients were included in each arm.

Patients were treated with the ‘steri-strip sling technique’. Steri-strip^TM (manufactured by 3M^TM) is an adhesive skin closure strip that is reinforced with polymer filaments [Figure 1].

Figure 1.

Steri-strip^TM reinforced adhesive skin closures strips

Procedure

In an ingrown toenail [Figure 2a], without local anaesthesia, the lateral nail fold is retracted with a nail spatula, and the distal edge of the nail spicule is exposed [Figure 2b]. The edge of the nail plate is elevated and a Steri-strip^TM is inserted between the disto-lateral edge of the nail plate and the nail fold, and secured with cyanoacrylate glue. The ends of Steri-strip^TM are secured with an elastic bandage around the great toe [Figure 2c]. The dressing is replaced in case it comes off and kept till the nail spicule grows over the nail fold, reaches the hyponychium, and stops penetrating the skin.

Figure 2.

(a) Left great toe with ingrown toenail before treatment, (b) Lateral nail fold is retracted with nail spatula, and the distal edge of nail spicule (black arrow) is exposed, (c) Steri-strip^TM is inserted between the disto-lateral edge of the nail plate and nail fold and secured with an elastic bandage around the great toe, (d) Left great toenail after treatment

Patients were instructed to continue their routine activities without any restriction and wear loose-fitting shoes. Patients were also advised about the correct nail trimming technique and not to cut the nail at the edges. Patients were reviewed every week for a month after the treatment and once a month after that to check the dressing and monitor the nail trimming habits. The final result was assessed at the end of 6 months [Figure 2d]. To avoid bias, all patients were given a questionnaire at the end of the study and the success of the treatment was assessed clinically and by patient satisfaction levels.

Results

A total of 75 patients were assessed out of which 60 patients consenting to treatment were treated. At the end of 6 months, 10 patients were lost to follow-up and the result of 50 patients was analysed. The CONSORT statement of the study is shown in Figure 3. Out of 50 patients, 36 (72%) were male and 14 (36%) were female. The patients ranged from age 14 years to 58 years with mean age of 29.4 years. A total of 50 nails of 50 patients were treated. 18 had stage 1 disease and 32 had stage 2 disease.

Figure 3.

CONSORT Statement of the study

At 6 months follow-up, on the patient satisfaction scale; 46 out of 50 (92%) patients were satisfied with the treatment; 36 patients were ‘very satisfied’ and 10 were ‘satisfied’ [Table 1]. All patients reported complete pain relief within a week of the procedure. No complications were reported.

Table 1.

Assessment of response after 6 months of treatment

	Number of patients
Patient satisfaction level
Very satisfied	36
Satisfied	10
Neutral	02
Unsatisfied	02
Very unsatisfied	0
Clinical response
Complete resolution	46
Recurrence	04

On clinical assessment, 46 (92%) patients showed complete resolution of ingrown toenails and were asymptomatic at the end of 6 months. Figures 4–6 show ingrown toenails before, during, and after treatment showing resolution. Recurrence occurred in 4 (8%) patients with grade 2 ingrown toenails, of which two were neither ‘satisfied’ nor ‘unsatisfied’ with the therapy because they initially responded well and had early pain relief. In light of recurrence, two patients were unsatisfied with the therapy [Table 1]. Recurrence was attributed to their inability to adhere to instructions and incorrect nail trimming.

Figure 4.

Right ingrown toenail before, during, and after treatment showing resolution

Figure 6.

Right ingrown toenail before, during, and after treatment showing resolution

Figure 5.

Left ingrown toenail before, during, and after treatment showing resolution

Discussion

An ingrown toenail is a common nail problem frequently involving the great toe. Etiological factors include improperly trimmed nails, hyperhidrosis, excessive external pressure due to poor stance and gait, ill-fitting footwear, and trauma.[5]

Mozena[6] has classified onychocryptosis into four stages. The first stage is the inflammatory stage characterised by erythema, mild edema and pain on applying pressure to the lateral nail fold. The second stage is the abscess stage where pain, redness and oedema increase; and the nail fold extends over the nail plate. In stages 3 and 4, the nail fold becomes hypertrophic with the formation of granulation tissue.[6] There are various methods to treat ingrown toenails depending on the stage and severity of the condition. Patients with first to second-stage disease having mild to moderate pain, little erythema and no purulent discharge can be treated with conservative methods. A conservative approach at an early stage is preferable as surgical procedures at later stages lead to pain and affect routine activities.

Conservative therapy is a reasonable approach for mild to moderate disease. It is a cost-effective approach that avoids the need for surgical intervention at later stage. Common conservative techniques for treatment in early stages include warm water soaks, topical or oral antibiotics, elevation of the corner of the nail with a cotton wick,[7,8] band-aid method,[9] nail wiring,[10] gutter splint technique.[5,11,12] Gupta et al.[5] treated 50 patients with plastic tube splints and reported recurrence in 20.5% of patients. Wallace et al.[11] also treated 25 patients conservatively with the gutter splint technique but 48% of patients showed poor response. In both these studies, invasive procedures were done under local anaesthesia with some amount of blood loss. Many other conservative treatment modalities are reported in the literature with variable recurrence rates [Table 2].

Table 2.

Various conservative procedures for ingrown toenails with effectiveness

Author	No. of patients	Procedure	Follow-up time	Results (Patients improved)
Gupta et al.[5]	39	Nail splinting with a flexible tube	6 months	79%
Senapati et al.[7]	25	Cotton wool insertion under the toenail	2–56 weeks	79%
Lloyd and brill[8]	100	Cotton wool insertion under the toenail	2 years	50%
Wallace et al.[11]	25	Gutter splint technique	6 months	52%
Cameron[13]	100	Cotton wool insertion under the toenail	6 months	61%
Márquez-Reina et al.[14]	46	Application of polyethylene nail brace over nail plate	6 months	78.26%
You et al.[15]	27	Plastic tube insertion at the lateral edge of the nail plate	6 months	37%
Arik et al.[16]	41	Use of shape memory alloy device over the nail plate	612 months	80.5%
Shin et al.[17]	33	Gutter splint technique	Retrospective	72.7%
Abby et al.[18]	28	Modified sleeve method (Based on Wallace’s gutter splint method)	4 months	71.4%
Gutiérrez-Mendoza et al.[19]	10	Cotton nail cast	2 months	80%
Nazari[20]	32	Plastic nail tube insertion technique	6 months	93.75%
Taheri et al.[21]	11	Gutter splint technique	5 months	81.82%
This study	50	Steri-strip sling technique	6 months	92%

In medical literature, there is no consensus as to which procedure is most appropriate in the management of an ingrown toenail. The rate of recurrence of ingrown toenails with different conservative procedures varies widely. The treatment technique for ingrown toenails should satisfy the following criteria: minimal rate of recurrence; the patient should be able to wear normal footwear comfortably within a week of the procedure; a painless nail-bearing toe should be the end result; the procedure should be simple.[22] Our technique fulfilled these criteria for the management of ingrown toenails. In the present study, 4 out of 50 (8%) patients presented with recurrence, which is better than that observed with other conservative techniques [Table 2]. This procedure targets the basic pathology that is the nail spicule, without affecting the complete nail or nail bed. Separating the disto-lateral edge of the ingrown toenail from the adjacent soft tissue with the help of a steri-strip gives immediate pain relief and the nail spicule grows out without injuring the nail fold. Also, no complications occurred after the procedure. The technique has several advantages. It is simple, easy to perform and can be done as an outpatient procedure. The patient can walk immediately without restrictions as the pain disappears almost immediately after the procedure. There is no long-term functional or cosmetic impairment. This study demonstrates that mild to moderate ingrown toenails can be successfully managed in an outpatient department.

Limitation

The sample size is small as it is a pilot study. Patients suffering from severe ingrown toenails with granulation tissue formation were not included.

Conclusion

‘Steri-strip sling technique’ is an effective method for conservative management of ingrown toenails. This technique can be done without local anaesthesia as an outpatient procedure. However, further studies comparing this technique with the other techniques shall be needed for definite recommendations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.