by Last updated on March 7th, 2024 at 07:41 pm
Many people have never heard of the term involuted toenail or, more academically, a pincer toenail. Even those familiar with the term still don’t know what it is exactly. It is surprising to me as a clinician, although understandably, for something that is so common and can cause such pain, which can lead to an ingrown toenail (onychocrytosis) and possible infection, the ignorance surrounding it. This article will discuss what it is, what causes it, the problems it can cause and how to fix it. Read on to find out more!
What is an involuted toenail?
An involuted toenail is a condition where the toenail curves and grows down and inwards into the toe sulci (the fleshy bit at the sides of the toe). It is very apparent in severe cases. The nail is very curved and often causes pain, making it difficult to wear shoes and do daily activities. It can lead to an ingrown nail, but they are not the same since you can have involuted nails which are not pathological. In fact, in many cases, ingrown toenails result from other issues.
What causes involuted toenails?
There are many possible causes of involuted toenails. Some people have a genetic predisposition, which means it runs in the family. From a genetic point of view, Haneke (2012) suggested that the transverse over-curvature of the nail is believed to be a complex dominant trait in which the base of the distal phalanx (the bone at the end of the toe) is broad. There is also a build-up of osteophytes (extra bone growth) on the medial side (towards the body) of the toe (1). In other words, due to a genetic anomaly, the nail forms a tube-like shape leading to an involuted toenail.
Often, trauma to the nail can cause it to grow abnormally. Often, stubbing your toe, dropping something on your foot or wearing ill-fitting shoes are the main culprits. According to Bharathi and Banjantri (2011), the nail matrix and nail bed get damaged from the trauma causing the nail to grow abnormally. The nail matrix is responsible for about 90% of nail growth and is very sensitive. Once damaged, changes in the toenail are permanent (2).
Systemic disease and certain medications can also contribute to the development of involuted nails. Hernandez and Deleon Mayayise (2011) believe systemic diseases such as psoriasis, lupus erythematosus, Kawasaki disease and gastrointestinal malignancies can contribute. Other causative conditions include implantation cysts, onychomycosis (nail fungus) and myxoid cyst. How these illnesses cause the nail to become involuted remains unknown.
Medications such as beta-blockers and pamidronate have also been associated with the occurrence of involuted nails. Again, the mechanism as to how these medications cause the nail to become involuted still remains a mystery (3).
What are the problems associated with involuted nails?
It is important to note that not all involuted nails are pathological. Many people are getting on with everyday life, living with involuted toenails without problems. Problematic involuted toenails can cause excruciating pain at the side of the nails where they squeeze or pierce the skin.
As previously mentioned, they can lead to an ingrown toenail, making it very difficult to wear certain shoes. Further, participating in sports or other physical activities can be difficult due to the pain it causes. Moreover, it is not uncommon for an ingrown toenail to cause a bacterial toe infection.
Involuted nails can be more difficult to trim and care for since the nail edges are not easily accessible. This can also make detecting issues such as ingrown nails more difficult. Additionally, involuted nails may be more prone to infection, as fungus can build up under the nail. If you have involuted toenails, it is essential to take extra care when trimming and cleaning them. Also, see a podiatrist if you notice any redness, swelling, or discharge from the area.
How do you treat involuted toenails?
For painful involuted toenail, a few treatment options are available. You can start by wearing shoes with a deeper and broader toe box. This will give the toes enough room and help to offload pressure. Ensure the footwear has a fastener to prevent the toes from clawing for grip, thus reducing stress and pain.
Cutting your toenails properly also helps. How is this done? Cut your nails following the contour of the nails. That is, cut the toenails according to how they grow. Please do not cut them back beyond the level of the tip or apex of the toe. Do not cut down the sides, as you could leave a spike, which could worsen the condition by causing the nail to dig into the skin, leading to an ingrown nail and possibly an infection.
Avoid cutting nails straight across or round if the toenails do not grow that way. Further, no evidence suggests that cutting a V-shaped notch in the nail will solve the problem. It may just be an old wives’ tale. In all my time practising as a podiatrist, I have not seen it done nor seen it in the literature. I am open to correction and new knowledge. What has been reported in the literature is a technique where a small strip is taken from the middle of the toenail longitudinally. This surgical procedure should only be carried out by a qualified health professional.
Nail brace
Some have tried various nail braces. The idea behind this is that the edge of the nails is pulled outward and up. As the nails grow out over time, it should correct the problem. This procedure offers some help, but the results may not be permanent as the nails grow from the matrix where the damage occurred. As such, you may have to reapply it in the future.
Please note that the procedure was mainly intended for the big toenail. Chiriac and Solovan (2014) have written about the use of nail brace treatment for ingrown toenails, which you may want to look at (4). Sano and Agawa (2015) also showed a novel approach using mechanical force control to treat pincer nails that is worth looking at (5).
Minor nail surgery
For a more permanent correction, you will need to see a podiatrist for an assessment. They will discuss a partial nail avulsion surgery under local anaesthetic with a phenol chemical to stop the nail corners from growing back. The benefits of the procedure include correcting the problem, reducing pain and eliminating the chance of you getting an infection.
There are some risks associated with it as well. These include nail regrowth, phenol burn, reaction to the local anaesthetic, pain (temporary), infection, delayed healing and permanent change in the shape of the nail. It is possible to have the sides of the nail removed without the phenol, but you would run the risk of the nails growing back and causing the same problem in the future.
Recent research by Delduca et al. (2020) has also shown that problematic pincer toenails can be treated using tazarotene topical gel twice daily for three months. This was a case report, and the findings should not be generalised. There was no recurrence at 1-year follow-up of the pincer, involuted, trumpet, tiled-shaped or plicated nails (6).
Involuted toenail vs ingrown toenail
An involuted toenail is not the same as an ingrown toenail. An ingrown nail is where the side of the nail grows into or pierces the skin. This can be caused by cutting your nails too short, injury, or fungal nail infection. The result is usually pain, redness, swelling and sometimes pus. Yes, an involuted toenail can lead to an ingrown nail, but it is not inevitable. In many cases, involuted nails are asymptomatic. That is, they don’t cause any problems.
FAQs
1. Can involuted nails be cured?
To date, there is no known cure for involuted nails as such. However, if the condition is causing pain or problems, there are treatments that can help. See a podiatrist.
2. What is the best way to treat involuted toenails?
If the condition is causing pain or problems, the best way to treat it is to see a podiatrist. They can assess the problem and recommend the best course of treatment. This may involve surgery or other interventions.
3. Are there any home remedies for involuted nails?
There are no home remedies that have been proven to be effective for treating involuted nails. However, some people may find that soaking the affected nails in warm boiled salt water or applying a cream or ointment can help to alleviate the symptoms.
4. Will an involuted toenail grow out on its own?
In most cases, an involuted toenail will grow out independently. However, that does not mean it is cured. If the condition is causing pain or problems, then there are treatments that can help.
5. Can you trim an involuted nail?
It would be best if you did not trim an involuted nail yourself, as this could worsen the condition. If the condition is causing pain or problems, the best way to treat it is to see a podiatrist. They will advise you on the best course of treatment.
Final thoughts
Involuted nails, pincer nails, trumpet nails or whichever other names they are known can cause excruciating pain. There are various treatment options available which can help resolve the problem in many cases. If you are having trouble with an involuted toenail, it could get worse over time, so you need to seek professional help. Always remember that your health is your wealth, do not suffer alone.
