Curing Ingrown Toenails - Once and for All

Ingrown toenails are an all to frequent problem encountered by family physicians. Often the toes are a mess when the patient presents to the office - swollen, red and pussy. Traditionally treatment has involved soaking, antibiotics, and a wedge resection of the offending nail. Unfortunately this procedure is often not curative and the patient is back in the office a few months later with a recurrence.

This article will present an alternate course of action - one that defines the problem as not the nail, but rather the surrounding soft tissue.

Dr Chapeskie has been using the Vandenbos Procedure successfully for several years to effect a complete cure. The procedure is not well known, and does require some courage and a leap of faith by both the physician and patient, but if performed as described below, it can save your patients years of agony.

A video of the procedure can be seen by following this link. (Note that this is a large video file - 98 MB zipped, and will require a program such as VLC to view it.)

The Vandenbos Procedure

A ring block with 3cc of 2% plain xylocaine is done at the base of the toe (1.5cc per side). Following this an elastic band or Penrose drain is wrapped snugly around the toe as a tourniquet. Something should be attached to the tourniquet (a flag or instrument, such as a tubing clamp) to ensure that you remember to remove it after the procedure! The toe is then cleansed with an iodine wash.

After about 5 minutes the toe is ready.

An incision is made proximally from the base of the nail about 5 mm (leaving the nail bed intact) then extended toward the side of the toe in an elliptical sweep to end up under the tip of the nail about 3-4 mm in from the edge. It is important that all the skin at the edge of the nail be removed. The excision must be generous and adequate often leaving a soft tissue deficiency measuring 1.5 by 3 cm. A portion of the lateral aspect of the distal phalanx is occasionally exposed without fear of infection. Antibiotics are not necessary as the wound is left open to close by secondary intention. Postoperative infection is not a problem. No cases of osteomyelitis have ever been reported.

After the skin is removed application of a silver nitrate stick helps to cauterize any bleeding points. A fine mesh tulle gauze (10 x 10 cm) is folded and placed directly over the wound. A snug dressing is applied (i.e. a roll of 5 cm gauze wrap). The elastic tourniquet is then removed. This entire procedure can be done in 13-15 minutes for one toe. Bleeding is usually a problem as soon as the patient puts the foot down. Keeping the foot elevated in the car can minimize this and once at home the patient should lie down and elevate the foot on a couple pillows. Analgesia will be required for 3 to 5 days, but will be quite variable from patient to patient. Acetaminophen with codeine/oxycodone will usually suffice. More potent analgesics may be necessary.

About 48 hours postoperatively the patient soaks the foot in warm water for 15-20 minutes gradually peeling the dressing off the raw area. This can be done immediately after taking a shower, which will help soften the dressing. Afterwards a couple of 5 by 5 cm square gauze pads are applied and held in place with wraps of bandage. The soaking procedure must be repeated faithfully three times daily as the wound gradually epithelizes from the periphery inward. ÊThis aids the healing and keeps the wound clean. In addition, adding 1 teaspoon of Epsom salt to the water helps to keep the granulation bed low and clean and reduces the need to use silver nitrate applications as the toe heals. The toe will be quite red and swollen from the IP joint distally for 1 to 2 weeks postoperatively. However, as noted above, antibiotics are not necessary.

The patient is seen weekly for the next 4-6 weeks to make sure healing is taking place adequately and the wound is being cared for. Cautery with silver nitrate can be used on the granulation bed to keep it from heaping up.

At about 4-6 weeks the wound has healed and the nail is now above the skin. After 2-3 months the color will normalize at the operated area and after 6 months it will look normal.Ê

Some Points to Consider:

1. For the ring/digital block: I use about 3 cc's of 2% Xylocane (without epinephrine) for each toe - 1.5 cc's for each side of the toe. Usually anesthesia is achieved in a few minutes and the procedure is finished in 5-10 minutes per toe
 
2. I use an elastic / silicone penrose drain tourniquet to prevent bleeding during the procedure. The toe swells up purple before the first incision but this bleeds off quickly and provides a nice dry bed to do the procedure. When removing the nail fold skin, be careful not to cut into or damage the nail matrix at the proximal area of the incision - this could permanently damage the nail shape, etc. I start the incision at the nail base, cutting out towards the side and then up to the tip of the toe. The incision must be generous and adequate. Occasionally, the lateral aspect of the distal phalanx may be exposed. This does not affect the healing and there have been no known cases of osteomyelitis.
 
3. After removal of the nail fold, roll a silver nitrate stick on the open wound along the side of the nail to help reduce the bleeding. Do not apply silver nitrate to the nail bed/matrix proximally - this may damage the normal nail growth. Then I apply a Sofra-tulle gauze onto the initial open wound. This helps with the first soaking and dressing removal. After a couple of 2x2's are applied, wrap a roll of 2" Sof-Kling gauze snugly to the toe. Keeping the foot elevated, remove the elastic tourniquet. Clearly, this final step is critical!
 
4. I sometimes put the foot in a plastic grocery bag for the trip home in case it bleeds through the gauze. Keep the foot elevated in the car! The patient is given an instruction sheet for post-operative care regarding soaking, etc.
 
5. I provide a package of non-sterile 2x2s (200) and a few rolls of kling wrap.
 
6. The first 24-48 hours post-op can be very painful. Start pain meds early! I usually use Percocet from age 15 and up (Tylenol #3, under age 15). Some patients do not respond well to Oxycodone or Codeine. For these patients, I use Demerol 50mg, 1-2 tablets every 4 hours (Pediatric dosing: 1-1.75 mg/kg q4h). I usually give them a separate prescription Demerol tablets in case they need to change medications. Some patients will only require 2-4 analgesic tablets in the post-operative period and others will require 30-40. By 3-5 days, pain medication is usually not required.
 
7. The 3-times/day soakings are critical and must be reinforced to the patient. This must be done until the wound is closed in and usually takes 4-6 weeks. Adding 1-2 teaspoons of Epsom salt to the water helps to keep the granulation bed low and clean and reduces the need for silver nitrate application as the toe heals.
 
8. After the surgery I see the patient back weekly after that for 4-6 weeks. Occasionally, silver nitrate is applied at follow-up appointments to the granulation bed to keep it low. The sides of the nail often get stained black from this but will grow out clean and normal.
 
9. The distal half of the toe always look red and swollen initially (1cm around). This is normal. No antibiotics are necessary. In the first week or two the swelling and redness can become quite marked if the patient is walking a lot. Have them elevate the foot for a couple days and this will settle down.
 
10. Patients can be up and about as tolerated after the first 24 hours. However, if they are up too much in the first 12-24 hours, the wound will bleed through the dressing. Tell them to keep it elevated and add more dressing if necessary. No sports, gymnastics, jogging, etc., until the wound is completely closed in and dry - about 4-6 weeks.
 
11. I have had two or three patients with a small residual granulation area at the side of the nail - usually only a few millimeters in length - that has persisted after the normal healing period (4-6 weeks). Silver nitrate use every 3-4 days may burn this back and allow the skin to close over. If, by the 8-week mark, the skin has not closed over, then with a small local anesthetic in the area, it can be wedged out and the skin usually closes over the area in 2-3 days. All have healed perfectly.
 
12. The initial application of a snug, bulky dressing eliminates the need to tie off bleeders as Dr. Kermit Vandenbos describes. He also says that daily dressings are not necessary, however, the granulating wound weeps a messy discharge and the dressings help keep socks and sheets clean and dirt, etc, out of the wound.
 
13. I reassure my patients that the cosmetic result will be excellent and that the problem should never recur.

If you have any questions at all, don't hesitate to contact me. I firmly believe that you will be impressed by the results and your patients will be pleased as well.

Dr. Saadia Hameed

You can search for abstracts of the above references by following this link: PubMed