Introduction

Ingrown toenails, also known medically as Onychocryptosis, are a common nail disorder associated with diabetes. Due to their heightened risk of infection and slower healing rates, ingrown toenails can be particularly troublesome for individuals with diabetes. This article will provide an overview of the causes, symptoms, and management strategies for ingrown toenails in people with diabetes.

Causes of Ingrown Toenails

Ingrown toenails occur when the edge of a toenail grows into the surrounding skin. This can lead to pain, redness, and swelling. The big toe is the most likely affected by an ingrown toenail.

Understanding the causes of ingrown toenails is crucial for individuals with diabetes as it can help them take preventive measures. Here are some common causes of this condition:

Improper Trimming: Cutting toenails too short or not straight across can encourage the corners of the nail to dig into the skin.

Tight Shoes: Too tight or narrow footwear can compress the toes, pushing the skin into the nail plate.

Injuries: Any trauma to the toenail, such as stubbing your toe or dropping something heavy on your foot, can cause an ingrown toenail. Activities involving repeated pressure on the toes can also lead to this condition.

Genetics: Some people are born with toenails that are more curved or thick, which makes them more susceptible to becoming ingrown.

Poor Foot Hygiene: Not keeping your feet clean and dry can lead to various foot problems, including ingrown toenails.

Fungal Infections can cause the toenail to become thick or warped, increasing the risk of ingrowth.

The Risks of an Ingrown Nail When You Have Diabetes

In people with diabetes, several factors contribute to the likelihood of developing infection and gangrene of the affected toes:

Poor Circulation (Peripheral Arterial Disease): Diabetes can impair blood flow to the feet, slowing healing and increasing susceptibility to infections.

Nerve Damage (Diabetic Neuropathy): Diabetic neuropathy can significantly reduce foot sensation, which may prevent patients from feeling pain associated with an ingrown toenail. Without the normal pain response, an ingrown toenail may go unnoticed and untreated for a more extended period, increasing the risk of severe infections and complications such as ulcers or even gangrene.

Foot Deformities: Diabetes can lead to changes in foot shape, which might cause abnormal pressure on the toes and nails.

Big toe gangrene as a result of ingrown nail infection

Symptoms to Watch for

Individuals with diabetes must monitor their feet regularly for signs of ingrown toenails, which include:

1. Redness and swelling around the nail – The affected area may appear red and swollen due to inflammation caused by the body’s immune response to the infection.
2. Pain or tenderness when touching the toe– Diabetic foot wounds can be painful or sensitive. In some cases, patients may experience a loss of sensation in the affected area due to diabetic neuropathy.
3. Pus or fluid discharge– Pus or fluid may ooze from the wound, indicating an active infection that requires immediate medical attention.
4. Foul smelling– An unpleasant smell from the wound may indicate a severe infection.

Grading of the Severity of Ingrown Toenails

Understanding the grading of the severity of ingrown toenails is crucial for effective treatment. Ingrown nails typically progress through three stages:

Mild (Stage 1):

Redness, swelling, and pain are usually present along one or both sides of the nail (lateral nail fold).

Moderate (Stage 2):

As the condition worsens, the symptoms become more pronounced. The affected area may become more swollen and painful with discharge, indicating a bacterial infection.

Severe (Stage 3):

In the most advanced stage, the ongoing infection and worsening symptoms can lead to the overgrowth of granulation tissue around the toenail.

An abscess may develop when the infection spreads to a broader area of the affected toe, requiring more intensive treatment, possibly including surgery.

Preventive Measures

Preventing ingrown toenails is particularly important for people with diabetes. Some preventive measures include:

Proper Nail Trimming:

Cut toenails straight across without trimming the corners, and avoid cutting them too short to prevent ingrown nails.

Straight across beyond the nail bed

  Too rounded

  V-shaped trim

Too short

Appropriate Footwear:

Shoes that fit well and provide enough room around the toes can help prevent pressure on the nails.

Regular Foot Checks:

These are vital parts of self-care for individuals with diabetes. A daily inspection of the feet can help catch early signs of problems, including ingrown toenails, before they escalate.

Conservative Management

Conservative management is highly effective for early-stage ingrown toenails.

Elevation of the ingrowing nail edge: 

Use a pair of forceps to pack a small piece of cotton wool under the free corner of the nail. Similarly, one can also use dental floss or a gutter splint to place under the edge of the nail to prevent it from digging into the surrounding tissue.

Elevation of ingrown nail edge with cotton

Elevation of ingrown nail edge with gutter splint

Elevation of ingrown nail edge with dental floss

Topical Antibiotics/antiseptics:

Applying antibiotic / antiseptic ointment to the affected area can help prevent infection and promote healing.

Pain Relief: 

Use over-the-counter painkillers, such as Nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol, to help reduce pain and inflammation.

When to See a Doctor

Individuals with diabetes should take ingrown toenails seriously, as even minor foot injuries can lead to severe complications. These complications include the risk of developing gangrene, which could result in the loss of a limb. Poor circulation, common in diabetes, further increases the likelihood of infection and impedes healing, making immediate medical attention crucial.

If you develop a foot wound because of an ingrown toenail, you should never attempt self-treatment. Early specialist intervention can prevent serious complications.

Managing the symptoms and seeking a permanent solution to prevent recurrence is crucial.

Professional Management and Treatment

Assessment for circulation: 

Assessment of blood supply to the foot in people with diabetes before undergoing any toe surgery or treatment is crucial because of the risk of compromised circulation often associated with diabetes. Poor blood supply can significantly increase the risk of infection and gangrene following surgical interventions.

Surgical options: 

There is still no agreement on the most effective treatment for ingrown toenails. Managing ingrown toenails can be tricky, and the best treatment often depends on the severity and frequency of the problem. Here are some common approaches:

Simple nail avulsion/wedge excision (Not recommended)

Both nail avulsion and wedge excision are common procedures used to treat ingrown toenails. During these procedures, the part of the nail causing the ingrown toenail is temporarily removed. However, the nail matrix, the tissue under the skin that produces the nail, is not treated. If the nail matrix is not treated, the nail will likely grow back in the same pattern, potentially leading to the same ingrown condition. Therefore, it is essential to treat the nail matrix to prevent the recurrence of an ingrown toenail.

Partial Nail Avulsion with Phenol Matricectomy

This is one of the most common procedures. It involves removing a portion of the toenail (of the affected side) and applying a chemical called phenol to the nail matrix. The phenol destroys the matrix cells, preventing regrowth of the nail at the treated site and thereby reducing the chance of recurrence. This treatment is highly effective, with a high success rate and low recurrence of ingrown toenails.

Wedge Resection with Surgical Matricectomy (Zadik’s Procedure)

This surgical technique removes a wedge-shaped portion of the nail and the underlying nail bed and matrix (nail root). This method is highly effective for preventing recurrence and is often used when the ingrown toenail is recurrent or severe.

Complete Nail Avulsion with Matricectomy:

In more severe cases, the entire nail may be removed, followed by matricectomy. This is a less common procedure for ingrown toenails unless the problem is extensive. Complete nail avulsion can be followed by matricectomy if there is a high risk of recurrence.

Debridement and drainage of pus

In cases associated with severe infection, debridement and drainage of pus may need to be carried out before proceeding to any definitive nail procedure. Antibiotics are often required in this situation.

Conclusion

Effective management of ingrown toenails is crucial for individuals with diabetes as part of their overall foot care. Regular foot inspections, preventive measures, and prompt treatment are key to avoiding complications and maintaining good foot health. Those with diabetes should work closely with their healthcare providers to manage their foot health and prevent problems such as ingrown toenails.