A 14-year-old boy presented at Leading Edge Podiatry with a chronic ingrown toenail in his left big toe. He reported that the pain had been present for 4 weeks. He initially saw his General Practitioner who prescribed antibiotics Flucloxacillin for 10 days. This helped reduce some of the pain initially however, after 2 weeks it became more inflamed with a large red lump of skin forming on the side of the nail. He has been salt bathing the foot but it is not providing much pain relief. He previously had the same issue on the same toe 1 year ago and 6 months ago. His father also has had some ingrown toenail problems. He was a keen soccer player and had been unable to play due to the pain.
Patient’s Pain Symptoms
The patient reported that the pain was present in his left big toe. The onset of pain was when he first noticed the nail growing into the skin. It was initially sore just wearing shoes but recently sore with pressure against bedsheets and socks. The pain was worse when wearing shoes and when playing soccer. The patient described the pain as a sharp, throbbing sensation in the toe. There was pus initially when seeing the General Practitioner but none since. It is too sore to touch. The patient has a history of anxiety with needles. His goal is to return to playing soccer.
Examination and Assessment
The podiatrist carried out a thorough examination, beginning with a comprehensive history-taking. The patient’s foot was examined and compared to the opposite foot’s big toe. The toenail is curled at the sides and very broad pushing against the skin. It was too tender to press, warmth was noted and red inflamed raw tissue was noted. No pus or discharge was observed.
Diagnosis and Treatment
The podiatrist diagnosed the patient with a chronic ingrown toenail. Unfortunately, the antibiotics only helped settle the bacterial infection. The nail was still piercing into raw skin/tissue and not settling the pain. Given the family history and ongoing issue with the ingrown toenail, the patient was recommended to have minor ingrown toenail surgery. This involves injecting a local anaesthetic and removing the offending edge (partial nail avulsion) and applying a chemical to burn the “root” of the nail to prevent regrowth. To complete local anaesthetic injection the patient was first administered Methoxyflurane (aka “The Green Whistle”) which reduced the anxiousness of the patient and the pain from the injection.
The nail surgery involved removing the offending edge and inflamed tissue and applying phenol to the nail matrix. The nail surgery took 20 minutes to complete and without complications. The patient was advised to wear open-toed shoes and to keep the area clean and dry and reviewed 2 days later. His mother helped take the patient to and from the clinic back home
Upon the review appointment, the pain was only mild for the 24 hours following nail surgery. The inflamed skin had greatly reduced. The patient was then advised to redress daily for the following 2 weeks with reviews taking place weekly. He was able to wear enclosed shoes and complete day-to-day activities, just avoid running and kicking ball sports. After the 3-week review, the toe was no longer sore, a scab had formed at the surgical site. The patient was very pleased with the outcome as he could return to soccer and had no worries about the ingrown toenail recurring.
