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- Presentation
Pincer Nails and Ingrown Toenail Management: Conservative and Surgical Approaches
Description
The talk reviewed pincer nails and ingrown toenail management, emphasizing that nail curvature is often driven by biomechanics and loss of normal ground reaction forces, especially in older, less mobile patients, but can also be associated with conditions such as onychomycosis, psoriasis, beta-blocker use, lupus, Kawasaki disease, ALS, and hemodialysis. Conservative options included acetylcysteine plus nail braces, topical agents like tazarotene, YAG laser, suture-based flattening, and orthodontic-style wire bracing; these can reduce pain and curvature, but recurrence is common and long-term data are limited, particularly if an underlying bony deformity is present. The speaker stressed obtaining weight-bearing radiographs before treatment to look for distal phalanx deformity, since total nail avulsion alone may worsen outcomes or create a disappearing nail bed. Surgical approaches discussed included a zigzag/M-W procedure with tissue advancement and a partial nail avulsion technique when no osteophytes are present, though stability concerns remain. For ingrown toenails, the distinction between onychocryptosis and paronychia was reviewed, along with common causes and the need to rule out serious pathology such as melanoma or osteomyelitis when indicated. Treatment options ranged from conservative trimming, urea occlusion, splinting, taping, and steroid injection to partial nail avulsion with phenol matrixectomy; the speaker preferred a less traumatic technique, about one minute of phenol exposure, simple dressing, postoperative topical drops, avoidance of soaking, and no routine oral antibiotics.
View moreConclusions
- Pincer nails appear to be driven in part by biomechanical imbalance, so restoring normal mechanical forces may help but does not always provide a durable fix.
- Conservative treatments can reduce nail curvature and pain, but the benefits are often temporary and recurrence is common after treatment stops.
- Adjunctive conservative options such as tazarotene, Nd:YAG laser, suturing, and orthodontic wire techniques may improve nail shape in selected patients, but long-term evidence is limited.
- Plain radiographs are important before treating pincer nails or severe ingrown nails because an underlying distal phalanx bony deformity may determine the best management.
- When no bony deformity is present, partial nail avulsion with matrix-directed procedures can flatten pincer nails with good medium-term results in some patients.
- Total nail avulsion alone is not ideal for pincer nails because it may worsen nail-bed problems and does not address the underlying deformity.
- Surgical correction is generally more definitive than conservative care, but it carries risks and may require collaboration when bony correction is needed.
- Ingrown toenails and paronychia should be distinguished because the management and underlying pathology are different.
- Risk factors for ingrown nails include poor nail trimming, shoe pressure, nail deformity, thickened or thin nail plates, medications, and biomechanical abnormalities.
- Clinicians should consider infection, osteomyelitis, vascular status, diabetes control, neuropathy, and even amelanotic melanoma in chronic or atypical nail inflammation.
- Partial nail avulsion with phenol matrixectomy remains a core surgical treatment for ingrown nails and is usually followed by simple local wound care rather than soaking or routine oral antibiotics.
- Postoperative topical drops and dressing care can provide acceptable healing and pain control, while oral antibiotics usually do not improve outcomes.
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