SURGICAL OPTIONS IN THE MANAGEMENT OF INGROWING TOE NAILS IN PAEDIATRIC AGE GROUP

Abstract

Introduction: The problem of ingrowing toenails is worldwide, affecting all age groups. The exact incidence in children is difficult to measure.

The aim of this study was to review the different surgical modalities for ingrown toenails in the paediatric age group in a hospital setting.

Methods: We reviewed case series of 66 children aged between 9 months and 16 yrs. In total there were 89 affected toes operated upon between 1995 and 2001. The patients were followed up for up to 18 months.

All procedures were carried out under general anaesthetic. The treatment methods practised were:

1. Nail avulsion with or without nail matrix ablation using phenol.

2. Wedge excision of the nail with or without nail matrix ablation using phenol or thermal ablation.

RESULTS: We performed statistical analysis using Fischer’s exact test with the level of significance at P value 0.05. We found the recurrence rate to be 3% for those treated with wedge excision alone compared to 30% when treated with wedge excision and phenol ablation (p=0.001).

We also applied the same Fischer’s exact test for rate of infection in all the groups.

DISCUSSION: Ingrown toenails go through three stages- inflammation, infection and granulation.

During the stage of inflammation, conservative measures in the past have been noted to be successful.

In a hospital setting, most patients present in the second stage (infection). Nail avulsion is still commonly practised as a first line treatment. It provides good symptomatic relief in this stage but has been reported to have high rates of recurrence. We noted similar results (recurrence rate: 55%) in our study.

Then patients present in the next stage with symptoms of chronic ingrowths i.e. previous infection and presence granulation tissue in the nail fold. The aim of treatment here is to remove the ingrown area along with the nail fold. Wedge excision with or without removal of nail matrix is a commonly performed procedure. There are various methods for removing the nail matrix namely surgical matrixectomy, chemical matrixectomy using phenol or sodium hydroxides, diathermic/electric cauterisation, laser. There are reports that show low recurrence rates with use of phenol. In this study we found recurrence and infection to be high when phenol was used as the ablative agent. We achieved cure rate of 97% when using wedge excision alone and 70% when phenol was used for nail matrix ablation.

CONCLUSION: We advocate wedge excision as primary treatment of ingrowing toenails in children. We did not note a statistical significance in giving postoperative antibiotics but this has to correlate with the clinical presentation. We would not recommend phenol ablation of the nail matrix in the younger patient as it increases both infection and recurrence rates. The results of nail bed ablation with diathermy appear promising.