Last updated on March 7th, 2024 at 07:50 pm

If you have ever had an ingrown toenail, you would agree that it is an experience you would not like to reoccur. About 20% of people who see a general practitioner for foot-related problems have an ingrown toenail. It’s one of the major causes of toe pain. The first stage of a mild ingrown toenail is the most critical as it’s easier to solve with proper intervention. This article will discuss how a first-stage mild ingrown toenail presents itself and how it contributes to the second and third stages. We will also look at conservative and surgical management. Read on to find out more!

What exactly is an ingrown toenail?

The correct medical term for an ingrown toenail is onychocrytosis or unguis incarnates. For the layperson, an ingrown toenail is when the corner or side of the toenail grows into the skin. This can happen to either or both sides of the nail. The big toe is mainly affected. It can cause pain, redness, swelling, and sometimes an infection due to bacteria entering the body where the nail pierces the skin.

What causes first stage mild ingrown toenails?

The leading cause of first-stage mild ingrown toenail is poor nail care. This involves not trimming your nails properly or wearing tight shoes. It is prevalent in teenage boys and young people who pick their nails instead of cutting them properly. Other causes include trauma, such as stubbing your toe or having diabetes or poor circulation.

Also, individuals with pincer or involuted toenails, sweaty feet, excess weight, medical conditions that can lead to water retention in the feet, and those taking cancer medications are at increased risk of developing an ingrown toenail (1).

What are the symptoms of first stage mild ingrown toenails?

The first stage of a mild ingrown toenail is erythema (redness) around the area, oedema (swollen) and pain at the nail corners. This can affect any toe, but the big toe is mainly affected. The first symptom you will experience is usually pain. The pain is caused by the nail edge growing into the flesh.

In the second stage, there is a marked increase in the pain that is felt. Puss or exudate drains from where the nail pierces the skin, and paronychia (infection caused by bacteria) can develop. In the third stage, hyper-granulation (raised excess tissue mass) forms at the sides of the nail. This is basically the body reacting to the irritation from the nail and developing extra tissue in an effort to protect itself (2).

How is the first stage of mild ingrown toenails diagnosed?

Diagnosing an ingrown toenail is straightforward. Your clinician will ask you ask about the history of the condition. They will also examine the shape of the nail and look for pain, redness, swelling, exudate, and infection to help determine if it’s a first, second or third-stage ingrown toenail. Mild irritation may suggest a first stage ingrown toenail if the former signs are absent. Further investigations are often not warranted unless the clinician suspects something more benign is happening.

What are some conservative home treatments?

If you have a first-stage mild ingrown toenail, there are some things that you can do at home to help ease the pain and discomfort. You could start by soaking your foot in warm, boiled salt water for about 10 minutes daily. It will help reduce swelling and pain. You can also take over-the-counter pain medication to help with the pain. If pus or exudate is present, clean it and apply a sterile dressing to protect it.

Other things you can try

Below are some things to try if what we previously discussed fails.

• Cotton wick – You can place a small amount of cotton under the part of the nail that is problematic to elevate it to offload the pressure.
• Dental floss – This is an alternative to the cotton wick, and the technique is done the same way.
• Taping – Apply one edge of the tape at the side of the ingrown nail. Then pull it down, under and over the toe to pull the skin away from the nail edge causing the problem, thus reducing pressure and pain. If you have sweaty skin, the technique may not work.
• Splinting – To do this, cut off a small portion of a vinyl intravenous tube. Cut it open from top to bottom. Place it between the nail edge and the skin. It will separate the nail edge from the skin and should relieve pain instantly in most cases. Please note that the tube must be sterilized before use, or you could risk getting an infection.
• Nail brace – This involves using a wire with a hook-like shape on either end to elevate the nail edge. There are other braces on the market of various makes and sizes. Some of them have a lever mechanism on top, when turned, allows either side of the nail to be elevated.

It is important to note that these are not necessarily permanent fixes. However, they offer relief to what would otherwise be an excruciating problem (3).

Surgical fix for ingrown toenails

The first stage of mild ingrown toenails can often be treated conservatively. However, if conservative measures fail and the problem is recurrent, painful and leads to infection, the best option is a surgical fix. The surgery is straightforward, complications are rare, and the success rate is well over 90%. The procedure can be done under local anaesthesia in the clinician’s office.

The procedure is called an avulsion. It can be a partial nail avulsion (PNA) or a total nail avulsion (TNA). PNA involves removing a small portion of the nail, while TNA is removing the toenail completely. A chemical called phenol is typically used to prevent the part of or nail taken out from growing back. 

However, there are occasions when a clinician may not want to use phenol. This may be due to the patient’s wish or if they think the nails stand a chance of growing out without the problem reoccurring. For example, if the ingrown nail was due to cutting the nail poorly and the nails were not damaged or involuted.

What to expect on the day of ingrown toenail surgery

Remember, the surgery will only be done where there is no alternative recourse to fix the problem permanently. On the day of surgery, you will be made to relax. The clinician will go over the procedure with you. They should explain the advantages and disadvantages. 

The advantages of a minor nail surgery procedure include the following:

• Correcting the problem.
• Reduces the chance of you getting an infection from it in the future.
• Stops any pain you are getting.

As with everything surgical, there are risks associated. The disadvantages include the following:

• Anaphylactic shock – Some people may get an anaphylactic shock or reaction from the local anaesthetic where they may feel faint, confused, have difficulty breathing, have an increased heartbeat, and lose consciousness, among other things. This is very rare, and there are always procedures in place to deal with it.
• Phenol burn – The chemical used to stop the nail from regrowing, if care is not taken, can cause damage to the surrounding tissue.
• Infection – This sounds counterintuitive, but due to the nature of the surgery, it is possible to get an infection at the surgical site. Most of the time, this is due to poor compliance and the part of the patient.
• Nail regrowth – This can sometimes occur in a tiny percentage of patients, generally due to poor surgical technique or some anatomical anomaly.
• Pain – Some patients may feel pain in the toe when the local anaesthetic is being administered and/or post-op pain.
• Delayed healing – Healing times vary for individuals, typically 4-6 weeks and 8-12 weeks if delayed.

Questions you will be asked on the day of surger

1. Your clinician will also need to find out if you have had local anaesthetic in the last 24hrs. This is to ensure you are not given more than the recommended amount within a 24hrs period. Doing so could lead to anaphylactic shock, as mentioned earlier.

2. If you are a female, they will also want to know if you are pregnant or breastfeeding. This is because your circumstances may have changed since the last time you were seen and pregnancy and breastfeeding are contraindicated for minor nail surgery. However, based on data from research, the conclusions on this are mixed. For this reason, some clinicians do not see pregnancy and breastfeeding as contraindications.

3. Your clinician will want to know if you are still happy to go ahead with the minor nail surgery procedure. If this is the case, they will get you to confirm what toe or toes will be operated on and whether it will be a partial or total nail avulsion.

The minor nail surgery procedure

Please note that techniques and procedures vary from one clinician to the other. You will be made to relax. The toe or toes will be cleaned with a sterilizing agent. Your doctor or clinician will ask for your permission to administer local anaesthetic. Remember that some people find the injection painful while others don’t. Nevertheless, that’s the only pain you should feel.

The clinician will check after a short period to ensure the toe is numb. If you feel any pain during the procedure, your podiatrist or doctor should stop right away and administer a small amount of local anaesthetic and check to make sure the entire toe is numb before proceeding.

If the toe is numb, the entire toe will then be cleaned to eliminate all bacterial agents. The foot may then be draped, and a tourniquet or an elastic band like the device will be placed over the toe to stop blood from getting into the area where the operation is taking place. This device has a time limit, as stopping the blood to the toe for too long can cause severe or permanent damage. 

How much of the nail is removed

Depending on the type of surgery, one corner, both, or the entire nail will be gently lifted. If it’s a TNA, the whole toenail will be removed. For a PNA, the offending section will be removed. Phenol will be applied to the nail bed and matrix to stop that part or the entire nail from regrowing. As good practice, some clinicians may use saline or some other agent to wash away any residue of phenol from the surgical site. The tourniquet will be removed, and a large dressing will be used to protect the toe and absorb blood.  

The patient will be sent home with their career. They should not drive or be on their feet for extended periods. The patient should elevate their feet and avoid alcohol. Paracetamol can be taken for pain but NSAIDs. A few days off from work is necessary, and wearing tight shoes should also be avoided. Try to attend all follow-up appointments. This is to ensure that healing is going smoothly.

Final thoughts

Having a first stage ingrown toenail is not the end of the world, and effective treatment options are available. If you are suffering from an ingrown toenail, see a podiatrist. They can diagnose and develop an appropriate treatment plan to help you fix the problem. Your health is your wealth! Always seek help!