Ingrown toenails (also known as onychocryptosis) are one of the most common foot complaints. Ingrown Toenails, occurs when the nail plate aggravates the surrounding nail fold or skin. They can cause intense pain, redness, swelling and can lead to infection.
The great toe is the most common site for ingrown toenails, however they can occur on any of the toes. Some of the more common causes for ingrown toenails to develop are: trauma or injury to the nail; the structural shape of the nail; poor cutting technique; digital deformities and ill-fitting footwear.
In some cases, a Bone Spur (syn. Subungual Exostosis) can grow underneath the toe nail and mimic an ingrown toenail. Painful Bone Spur can occur from trauma to the toe, such as stubbing a toe. They can also occur from minor repetitive trauma, such as impaction of the toe against footwear, such as steel cap or narrow toed shoes.
A Bone Spur under the toenail generally causes pain at the tip of the toe or toenail (as opposed to the nail fold). Contact of the shoe on the tip of the toe will often cause pain. As opposed to ingrown toenails, pain from a bone Spur can occur without redness, swelling or infection. Sometimes, bone spurs can lead to nail changes, such as a thickened or foreshortened nail plate. Painful Bone Spurs will often need removal to provide relief of symptoms.
Direct trauma to the toe or nail plate can lead to a variety of painful nail and toe conditions. The most common conditions include a blood blister or bleeding under the nail (syn. Subungual Haematoma). Bleeding under the nail is often very painful and requires immediate attention and drainage to relieve symptoms.
Trauma to the nail or toe can also cause nail bed and bone abnormalities, such as growth of new bone or skin, leading to derangement of the nail or end of the toe. In cases where painful extra bone or skin growth occur, surgical management may be necessary to remove the excess skin or bone to provide relief of pain or deformity.
Clinical photo of bruised nail (Subungual Haematoma).
Clinical photo of abnormal skin growth arising from the nail root following trauma to the toe.
Clinical photo of abnormal skin growth under the toenail (arrow) secondary to malunited bone fracture fragment.
X-ray of malunited bone fragment (arrow). Note the prominent bone growth.
Sometimes painful Corns can grow along the side of a nail. This most commonly occurs in crooked toes, such as hammertoes. Pressure from shoes against the tip or side of the toe can result in the growth of corns. Corns are a focal collection of densely compact skin cells. They can form alongside the side of a toenail or on the tip of the toe and mimic a painful ingrown toenail.
Removal of a small portion of the toenail can resolve painful corns that occur at the side of the toenail. Corrective toe surgery may be required in instances where toe deformity contributes to corn formation at the side or the tip of a toe or toe nail.
1. Clinical photo of a painful Corn present at the side of the right 4th toenail (arrow), masquerading as an ingrown toenail.
2a & 2b. Clinical photos of painful right 2nd toe from recurrent micro-trauma present at the tip of the toenail causing bruising of the toenail and corn formation at the edge tip the toenail (arrow). This is secondary to severe Mallet ToeDeformity.
COMMON BONE AND SOFT TISSUE GROWTHS
There are a variety of bone and soft tissue growths that can present as an ingrown toenail. The following is a list (not exhaustive) of more common growths of the toe that can mimic an ingrown toenail.
Hypergranulation Tissue (syn. Pyogenic Granuloma) is an overgrowth of skin-like tissue at the side of the nail due to irritation or trauma to the toe or nail plate. Hypergranulation tissue can occur in cases of longstanding ingrown toenails. This extra tissue is highly vascular and bleeds easily, often staining socks and bed sheets. It can grow rapidly and cover a large portion of the nail plate. The colour of the excessive skin growth can range from red to purple in acute or sub-acute cases or to skin colour in more long standing cases. The treatment of Hypergranulation tissue involves sharp removal of the tissue.
Clinical photo of Hypergranulation tissue present at the sides of the left big toenail secondary to chronic ingrown toenail.
An Osteochondroma is one of the most common benign bone tumours of the foot. It can be caused by trauma, but can also be congenital, i.e. associated with being present from birth. They are most commonly observed in people under 20 years of age. Osteochondromas are similar to simple Bone Spurs or Subungual Exostoses under the hallux nail plate. It involves a bone growth with a cartilage cap that can grow under the nail and distort the nail plate, often resembling an ingrown toenail. The treatment of Osteochondroma’s involves removal of the bone growth.
Clinical photo of a nail and toe distortion, secondary to large Osteochondroma of the toe bone (arrow).