Manejo de la onicocriptosis en atención primaria. caso clínico / Management of onychocryptosis in primary care: a clinical case

La onicocriptosis (uña encarnada) es una enfermedad ungueal de gran demanda en el servicio de atención primaria, molesta y limitante para los pacientes, con gran incidencia en el sexo masculino y en edades comprendidas entre la segunda y tercera décadas de la vida, de etiología indeterminada en la que intervienen una serie de factores tanto desencadenantes como predisponentes. El tratamiento depende del estadio en que se encuentre la uña encarnada e incluye desde procedimientos conservadores hasta intervenciones de cirugía menor que pueden ser realizadas por el médico de atención primaria en el centro de salud. Presentamos el caso clínico de un hombre de 25 años con onicocriptosis que no respondió a un manejo conservador y se realizó una extracción del extremo ungueal con matricectomía parcial (AU)

Onychocryptosis (ingrown toenail) is a condition commonly seen in Primary Care clinics. It is uncomfortable and restrictive for patients and has a high incidence in males between second and third decades of life. It is of unknown origin, with a number of predisposing triggering factors being involved. Treatment depends on the stage of the ingrown nail and the procedures may range from conservative to minor surgery that can be performed by the Primary Care physician in the health centre. We report the case of a 25-year onychocryptosis that did not respond to conservative management, and was extracted with partial matricectomy of the nail (AU)

Interventions for ingrowing toenails.

BACKGROUND: Ingrowing toenails are a common problem in which part of the nail penetrates the skinfold alongside the nail, creating a painful area. Different non-surgical and surgical interventions for ingrowing toenails are available, but there is no consensus about a standard first-choice treatment. OBJECTIVES: To evaluate the effects of non-surgical and surgical interventions in a medical setting for ingrowing toenails, with the aim of relieving symptoms and preventing regrowth of the nail edge or recurrence of the ingrowing toenail. SEARCH METHODS: We updated our searches of the following databases to January 2010: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, MEDLINE, and EMBASE. We also updated our searches of CINAHL, WEB of SCIENCE, ongoing trials databases, and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials of non-surgical and surgical interventions for ingrowing toenails, which are also known by the terms 'unguis incarnatus' and 'onychocryptosis', and those comparing postoperative treatment options. Studies must have had a follow-up period of at least one month. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies, assessed methodological quality, and extracted data from selected studies. We analysed outcomes as risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS: This is an update of the Cochrane review 'Surgical treatments for ingrowing toenails'. In this update we included 24 studies, with a total of 2826 participants (of which 7 were also included in the previous review). Five studies were on non-surgical interventions, and 19 were on surgical interventions.The risk of bias of each included study was assessed; this is a measure of the methodological quality of several characteristics in these studies. It was found to be unclear for several items, due to incomplete reporting. Participants were not blinded to the treatment they received because of the nature of the interventions, e.g. surgery or wearing a brace on the toe. Outcome assessors were reported to be blinded in only 9 of the 24 studies.None of the included studies addressed our primary outcomes of 'relief of symptoms' or 'regrowth', but 16 did address 'recurrence'. Not all of the included studies addressed all of our secondary outcomes (healing time, postoperative complications - infection and haemorrhage, pain of operation/postoperative pain, participant satisfaction), and two studies did not address any of the secondary outcomes.Surgical interventions were better at preventing recurrence than non-surgical interventions with gutter treatment (or gutter removal), and they were probably better than non-surgical treatments with orthonyxia (brace treatment).In 4 of the 12 studies in which a surgical intervention with chemical ablation (e.g. phenol) was compared with a surgical intervention without chemical ablation, a significant reduction of recurrence was found. The surgical interventions on both sides in these comparisons were not equal, so it is not clear if the reduction was caused by the addition of the chemical ablation.In only one study, a comparison was made of a surgical intervention known as partial nail avulsion with matrix excision compared to the same surgical intervention with phenol. In this study of 117 participants, the surgical intervention with phenol was significantly more effective in preventing recurrence than the surgical intervention alone (14% compared to 41% respectively, RR 0.34, 95% CI 0.17 to 0.69).None of the postoperative interventions described, such as the use of antibiotics or manuka honey; povidone-iodine with paraffin; hydrogel with paraffin; or paraffin gauze, showed any significant difference when looking at infection rates, pain, or healing time. AUTHORS' CONCLUSIONS: Surgical interventions are more effective than non-surgical interventions in preventing the recurrence of an ingrowing toenail.In the studies comparing a surgical intervention to a surgical intervention with the application of phenol, the addition of phenol is probably more effective in preventing recurrence and regrowth of the ingrowing toenail. Because there is only one study in which the surgical interventions in both study arms were equal, more studies have to be done to confirm these outcomes.Postoperative interventions do not decrease the risk of postoperative infection, postoperative pain, or healing time.

A comparison between CO2 laser surgery with and without lateral fold vaporization for ingrowing toenails.

BACKGROUND: An ingrowing toenail is an excessive lateral nail growth into the nail fold. It acts as a foreign body and exerts a local pressure sore-like effect, which may result in inflammation and granulation. Several treatment modalities exist, including chemical ablation and different surgical procedures. Here we describe and compare a simple and effective method of partial matricectomy using the CO2 laser (group A) versus a similar method with the addition of lateral nail fold vaporization (group B). OBJECTIVE: Outcome evaluation of a modified laser treatment modality for ingrowing toenails and determination of the role of lateral fold vaporization in reducing the recurrence of symptoms. METHODS: Forty patients (mean age 32.45 years) were treated with CO2 laser ablation of toenails between 1999 and 2005 by four physicians. One physician implemented a method that includes lateral nail fold vaporization and resection of the nail segment with its nail bed from 1999 to 2005. Three physicians implemented a similar technique but without lateral fold vaporization between 1999 and 2003, and added lateral fold vaporization to the performed procedure starting in 2004. RESULTS: The recurrence rate was 37.5% in group A and 6.2% in group B. The overall average disease-free follow-up period was 42.2 months. CONCLUSION: The use of CO2 laser in the treatment of ingrowing toenails offers an effective modality. We demonstrate the importance of lateral fold vaporization with the CO2 laser both in improving efficacy and in decreasing recurrence rates over a long follow-up period.

Surgical treatments for ingrowing toenails.

BACKGROUND: Ingrowing toenails are a common condition which, when recurrent and painful, are often treated surgically. OBJECTIVES: To evaluate the effectiveness of methods of the surgical treatment of ingrowing toenails. SEARCH STRATEGY: Electronic database searching (CENTRAL, MEDLINE, EMBASE, CINAHL) followed by investigation of reference lists of the papers identified from the initial search. SELECTION CRITERIA: Any randomised (or quasi-randomised) controlled trial which compares one form of surgical removal of all or part of a toenail due to its impact on the soft tissues to another or others. Studies must have a minimum follow period of six months and aim to permanently remove the troublesome portion of the nail. DATA COLLECTION AND ANALYSIS: Data extraction was carried out independently by the two reviewers using a pre-derived data extraction form and entered into RevMan. Categorical outcomes were analysed as odds ratios with 95% confidence intervals. MAIN RESULTS: Avulsion with phenol versus surgical excision: Phenolisation combined with simple avulsion of a nail is more effective than the use of more invasive excisional surgical procedures to prevent symptomatic recurrence at six months or more (OR 0.44 CI 95% 0.24 - 0.80). Avulsion with phenol versus avulsion without phenol: The addition of phenol, when performing a total or partial nail avulsion dramatically reduces the rate of symptomatic recurrence, (OR 0.07 95% CI 0.04 - 0.12). This is offset by a significant increase in the rate of post-operative infection when phenol is used (OR 5.69 95% CI 1.93 - 16.77). AUTHORS' CONCLUSIONS: The evidence suggests that simple nail avulsion combined with the use of phenol, compared to surgical excisional techniques without the use of phenol, is more effective at preventing symptomatic recurrence of ingrowing toenails. The addition of phenol when simple nail avulsion is performed dramatically decreases symptomatic recurrence, but at the cost of increased post-operative infection.

Factors affecting recurrence rate of ingrown toenail treated with marginal toenail ablation.

This retrospective study analyzed marginal toenail ablation for ingrowing toenails and the factors affecting recurrences. Recurrence was defined as a return of the previous symptoms, regrowth of the nail edge, or patient dissatisfaction with the clinical outcome. Based on these criteria, nine patients (10.7%) were considered to have had a failed operation. There were significant differences for recurrence rate (p <.05) in the patients operated on under local anesthesia and in previously treated patients. Full exposure and excision of the germinal matrix were essential to avoid recurrence.

Pain at first dressing change after toenail avulsion 2: findings and discussion of the data analysis.

A qualitative study was carried out on patients' and nurses' perceptions of pain following toenail avulsion. In part two of her award-winning paper, Brenda King discusses the patients' and nurses' responses to questions on expectations and pain.

Practical management of ingrown toenails.

An ingrown toenail acts as a foreign body, causing an inflammatory reaction and opening the way to secondary infection. Treatment consists of removing the offending portion of the nail and taking steps to prevent recurrence. The treatment should be simple to minimize expense, operative risks, and posttreatment disability. The most important step in preventing recurrence is teaching the patient the correct way to trim toenails.

Practical therapy for ingrown toenails.

The etiology, prevention, and previous therapies for ingrown toenails are presented. A simple, quick, relatively painless method for treating ingrown toenails is described, in which a cotton wick saturated with iodine tincture is inserted into the affected sulcus, separating the nail plate from the skin. Granulation tissue is treated with a cotton applicator saturated with a 50 percent silver nitrate solution. This method works on more than 80 percent of the ingrown toenails seen by this dermatologist, and is well tolerated by the patient.