Ingrown toenail: when to treat conservatively, when to operate and what stops it coming back
An ingrown toenail (onychocryptosis) hurts, bleeds, gets infected and, all too often, comes back. Many patients alternate between pharmacy remedies and poorly indicated operations that recur within a few months. The evidence helps put the decisions in order, and phenolisation of the nail matrix is the piece that changes the risk of the nail growing back into the skin.
Stages and treatment decisions
An ingrown toenail develops when part of the nail edge penetrates the lateral nail fold, causing inflammation, pain, bleeding and sometimes granuloma or infection. The Mozena classification divides it into stages I to IV: in stages I-IIa the nail can still be retrained and may settle without an operating theatre; in IIb-IV there is established granuloma, deformity or previous recurrence, and surgery with phenolisation of the matrix has the best evidence.
Early stages: spicule removal + nail bracing (orthonyxia)
Retraining the nail curvature reduces recurrence in early stages
RCT with 94 patients in Mozena stages I-IIa: spicule removal + nail bracing with a polyethylene strip significantly reduced recurrence at 12 months (p<0.001) compared with spicule removal alone, with measurable changes in nail width and curvature.
In early ingrown toenails, combining removal of the spicule with retraining of the nail curvature reduces recurrence compared with removing only the piece that digs in. It is an in-clinic treatment, no operating theatre needed, with good results while the stage is still correctable.
Márquez-Reina S, Palomo-Toucedo I, Reina-Bueno M, Castillo-López JM, Ortega JR, Calvo-Lobo C, et al. Polyethylene Nail Brace for Ingrown Toenails Treatment: A Randomized Clinical Trial. Int J Environ Res Public Health. 2020;17(21):7741. doi:10.3390/ijerph17217741
Surgery vs no surgery: when to operate
Surgery outperforms conservative care at preventing recurrence
Cochrane review with 24 studies and 2,826 participants: surgical interventions are more effective than non-surgical ones at preventing recurrence of an ingrown toenail. In the only study in which the compared operations were equivalent except for the phenol, recurrence was 14 % with phenol vs 41 % without phenol (RR 0.34; 95% CI 0.17 to 0.69).
The review also notes that complex postoperative protocols (routine antibiotics, special antiseptics, manuka honey) make no significant difference to infection, pain or healing compared with simple wound care. What matters is the quality of the procedure, not an elaborate aftercare regime.
Eekhof JA, Van Wijk B, Knuistingh Neven A, van der Wouden JC. Interventions for ingrowing toenails. Cochrane Database Syst Rev. 2012;(4):CD001541. doi:10.1002/14651858.CD001541.pub3
Phenolisation of the matrix: the game changer
Adding phenol can reduce recurrence by up to 87 % compared with surgery without phenol
Systematic review and meta-analysis with 36 studies and 3,756 participants: adding phenol to avulsion reduces the risk of recurrence by 87 % compared with surgery without phenol (RR 0.13; 95% CI 0.06 to 0.27; p<0.001).
The modern standard procedure is partial nail avulsion with chemical matricectomy using phenol: after removing the problem portion of nail, phenol is applied to the matrix for approximately one minute. The nail stops growing in that zone, and stops digging into the skin. Minimally invasive surgery, local anaesthetic, no stitches, quick return to activity. The review concludes that adding phenol is the difference between operating and operating well: the effect is consistent across the compared studies.
Exley V, Jones K, O'Carroll G, Watson J, Backhouse M. A systematic review and meta-analysis of randomised controlled trials on surgical treatments for ingrown toenails part I: recurrence and relief of symptoms. J Foot Ankle Res. 2023;16(1):35. doi:10.1186/s13047-023-00631-1
The real figure: recurrence below 5 %
With phenolisation of the matrix, recurrence stays below 5 %: around 95 in every 100 patients who have the operation have no further trouble with that nail. Without adding phenol to the procedure, recurrence rises to approximately 40 %.
A double-blind randomised clinical trial from the University of Seville with 108 affected nail folds compared application times of 88 % phenol (30 vs 60 seconds). The recurrence rate stayed below 5 % in both groups, with no significant differences (p = 0.99), and the 30-second application speeded up healing (15 vs 22 days). In other words, of every 100 patients operated on with well-performed phenolisation, around 95 or more have no further problem with that nail.
Muriel-Sánchez JM, Coheña-Jiménez M, Montaño-Jiménez P. Effect of Phenol Application Time in the Treatment of Onychocryptosis: A Randomized Double-Blind Clinical Trial. Int J Environ Res Public Health. 2021;18(19):10478. doi:10.3390/ijerph181910478
Take-home
- An ingrown toenail in its early stages can settle with spicule removal + nail bracing, without an operating theatre and with low recurrence when both are done.
- In advanced or recurrent stages, surgery is more effective than non-surgical treatment at preventing recurrence.
- Phenolisation of the matrix dramatically reduces recurrence compared with surgery without phenol: it is the technique with the best balance between recurrence and recovery.
- A well-performed matricectomy is what reduces recurrence most. Elaborate postoperative protocols (routine antibiotics, manuka honey, special antiseptics) add nothing over simple dressings, but basic care (hygiene, regular dressings and follow-up) is still necessary, above all in patients with excessive sweating or healing problems.
At Avanza Salud we can help
We treat ingrown toenails at every stage. In early stages we use spicule removal and nail bracing to retrain the nail curvature and avoid surgery when it is not needed. In advanced stages or recurrent cases we perform minimally invasive nail surgery with phenolisation of the matrix in clinic, under local anaesthetic, with no stitches and a quick return to activity. If you have been dealing with a nail that gets infected, bleeds or digs back in after every operation, the plan is worth reviewing: many recurrences happen because phenol was not added to the original procedure, or because a total nail avulsion was performed without treating the matrix, a technique that often fails to solve the problem and sometimes makes it worse when the nail grows back.