Ingrown Large Toe Nail

by Reece
(Ontario, Canada)

Dr. Mitnick,

I am a 46 year old Male Registered Nurse who is on my feet for a significant amount of time a day. I have a significant health history. I used to smoke about a 1/2 pack a day but quit in January 2010. In 2010 I had a triple bypass on my heart. After healing from that surgery my doctors wanted to check out the rest of my arteries. I had a lower leg angiogram done that indicated I had significant blockages in my lower legs. I am asymptomatic so the Vascular Surgeon said to hold off on any surgeries until I develop symptoms. My pedal pulses are absent at present. I am also a type 2 diabetic. My blood sugars are controlled at this point with diet and without oral medications or insulins. I have polycythemia. I know my hemoglobin levels are high when some of my toes on my foot turn bluish. At that point I get phlebotomy and it disappears.

I recently developed my first ingrown toe nail on the inner aspect on my left great toe. I have tried warm salt water soaks and to pull the spike out with sterile tweezers but it is extremely painful. Because I work in health care I have been given many different opinions on what I should do.

My questions are: Should I go see a surgeon because of my health history and the fact that I have blockages, or can I go see a podiatrist/Chiropodist?

Is it advisable/recommended to have the complete toenail removed and allow the nail to regrow on its own considering I have no/reduced blood flow to my feet? Should I get them to use Phenol or not?

Or should I elect for causing less trauma and just have my hang nail/spike pulled after freezing?

The reason I am asking is that I know a wound has a remote chance of healing with no blood flow. If I get the whole toe nail removed as opposed to just removing the hang nail am I at risk for losing the toe to gangrene, etc?

Thank you,

RESPONSE

Hi Reece,

People with your scenario present to my office all the time. This is where a foot specialist is the doctor of choice. I am not sure what the laws and training of a Canadian podiatrist entails, but here in the states, podiatrists are the specialist to see.
You are quite right to be concerned about an ingrown toe nail because of your medical history. The combination of diabetes and poor circulation is a terrible combination when it comes to foot problems.
Your worst case scenario would be for the toe nail to become infected. Because of diminished circulation you are almost at as much risk as an uncontrolled diabetic. It is the lack of circulation in an uncontrolled diabetic that is the most troublesome part of treating a diabetic foot infection.
Fortunately for you, your blood sugars are controlled and as you know bacteria have a predilection for "sweet" environments which can make infections even more difficult to treat.
First of all, I would stay away from phenol in your situation. Phenol destroys the nail matrix via a chemical burn and the last thing you want to do to your toe is create a burn. Diabetics, even controlled ones, have a greater tendency to develop burns that drain forever. This would be something you would want to avoid because of the increased chance of infection.
In my practice, in most cases I take a very conservative approach with patients similar to you. In most cases I am able to remove an ingrown nail without a local anesthetic, without much pain, and with minimal bleeding. That is what a podiatrist can do. You would be hard pressed to find a general surgeon or even a dermatologist who could do that.
Therefore, if you have an ingrown nail that can be removed with little fan fare, then that is the way to go, as far as I am concerned.
The other option is to have the ingrown nail permanently removed and when I say ingrown, I mean just the ingrown portion not the whole nail.
The problem here becomes one of bleeding or lack thereof.
Since I do not recommend phenol for reasons just stated, in order to remove the ingrown nail an incision would have to be made into the adjacent skin to manually destroy the matrix. Creating a surgical wound in a foot with poor circulation is just poor medical judgement.
So, if you were my patient I would treat the ingrown nail very conservatively, removing it on a regular basis.
If this conservative course did not give you the type of relief I anticipated, then it would be time for a vascular consult, to see if a procedure needed to be done in order to have enough circulation going into the toe to support a more invasive procedure.
I think it is important to note, that in most cases when I remove an ingrown nail conservatively in many instances when the nail grows back, it is no longer an issue.
In summary I would recommend conservative professional care, no "bathroom surgery" by you.

Marc Mitnick DPM
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