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Ingrowing toenail treatments


Why are ingrowing toenails a source of humour? As one Bandolier confidant said - 'they hurt'. Ingrowing toenails predominantly affect the big toe, often in adolescents and young adults because they have sweaty feet which softens the skin and nails. About 10,000 new cases needing treatment are thought to occur in the UK every year, about 20 per primary care group of 100,000 people.

Advice about basic foot care and appropriate footwear is sometimes enough to relieve the symptoms of pain and discomfort. Sometimes, though, it is necessary to remove the spike of nail growing into the skin causing the discomfort, with attempts to destroy the nail matrix to prevent regrowth. A systematic review [1] has examined the efficacy of various treatments.


A typically thorough Cochrane search eventually yielded nine randomised studies examining different methods of surgical nail treatments. The primary outcome was nail regrowth, and studies had to have a minimum follow up period of six month to allow for this to be measured adequately. One Dutch study was not included, awaiting translation, and information is being sought from authors to try and include information from other studies.


Comparisons were predominantly between avulsion of the nail with phenol treatment of the nail bed to prevent regrowth and several simple surgical procedures. For simplicity, and because there appeared to be no difference between the different procedures, these surgeries were combined.

Symptomatic recurrence at six months or more occurred in 14/288 (5%) patients treated with avulsion/phenol, and 33/297 (11%) patients treated surgically. For every 16 patients treated using avulsion/phenol, one would not have a symptomatic recurrence who would have had if they had been treated surgically (95% confidence interval 9 to 53).

Any recurrence (symptomatic or otherwise) at six months or more occurred in 46/352 (13%) patients treated with avulsion/phenol, and 82/367 (22%) patients treated surgically (Figure). For every 11 patients treated using avulsion/phenol, one would not have a recurrence, symptomatic or not, who would have had if they had been treated surgically (95% confidence interval 7 to 27). A brief examination of the non-included Dutch paper with 200 comparisons shows that even if included it would have made only minor changes for this outcome.

Figure: Individual trials showing the percentage recurrence (symptomatic or asymptomatic) of ingrowing toenails with surgery and phenol/avulsion. Diameter of point is proportional to number of patients in trial

Postoperative infection was reported in only two trials with 147 patients. It occurred in 12% of patients treated with avulsion/phenol and 18% of those treated surgically. This was not significantly different.


It is being suggested that ingrowing toenails are increasing in incidence in people treated for fungal nail infections, with 19 of 100 needing surgery [2]. The message is that both avulsion with phenol and surgical excision of ingrowing toenails work. Nine out of 10 patients will have no symptomatic recurrence over six months or more.

Combining the data from all the trials suggests that avulsion with phenol is statistically better than surgical excision, but one can see plenty of room for moving goalposts. The difference between the two techniques is small, and appropriateness will depend on local circumstances.


  1. C Rounding, S Hulm. Surgical treatments for ingrowing toenails. Cochrane Library 1999 issue 3 (13 March 1999).
  2. KL Connelley, SM Dinehart, R McDonald. Onychocryptosis associated with the treatment of onychomycosis. J Am Podiatr Med Assoc 1999 89: 424-6.
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