Dermatology Book

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Toenail Removal

Aka: Toenail Removal, Ingrown Toenail Avulsion
  1. Preparation
    1. Prepare site
      1. Immerse digit in warm soapy water for 10-15 minutes
      2. Prepare area with betadine or hibbiclens
    2. Digital Block anesthesia
    3. Consider Tourniquet (brief application only)
      1. Apply penrose drain or Rubber band at base of digit
      2. Reduces bleeding during procedure
    4. Drape area
  2. Technique: Toenail Removal
    1. Check for adequate anesthesia
    2. Elevate nail from nail bed
      1. Use nail elevator (periosteal elevator)
      2. Alternative instruments
        1. Closed tip of iris scissors
        2. English nail anvil
      3. Insert under cuticle and nail fold
    3. Identify line to cut nail
      1. Partial Nail Avulsion
        1. Lateral 1/4 of nail (where nail curves down)
      2. Complete Nail Avulsion: Midline of nail
    4. Use nail splitter of sterile bandage scissors
      1. Cut nail to proximal nail fold
    5. Grasp nail with hemostat
      1. Twist lateral fragment outward to remove
  3. Technique: Phenolization for matricectomy (Chemical nail ablation)
    1. Background
      1. Chemically destroy nail matrix
    2. Indications
      1. Indicated for recurrent ingrown nail
    3. Efficacy
      1. Phenolization is at least as effective as surgical method
      2. Gerritsma-Bleeker (2002) Arch Surg 137(3): 320-5 [PubMed]
    4. Adverse Effects
      1. Minor increased risk of infection with phenolization (prophylactic antibiotics not recommended)
    5. Contraindications
      1. Do not use phenol in the presence of a pregnant patient or pregnant medical staff
    6. Technique
      1. Phenolization uses phenol 80-88%
      2. Apply Phenol with cotton swab to matrix for 30 seconds each, and repeat 3 times
      3. Only apply phenol to nail matrix and not to nail bed or surrounding tissue
      4. Thoroughly cleanse with isopropyl Alcohol 70% (neutralizes phenol)
  4. Technique: Surgical Matrcectomy (nail ablation)
    1. See Phenolization above for indications
    2. Laser Method
    3. Electrosurgical method (Ellman Surgitron)
      1. Antenna lead placed beneath heel of foot
      2. Clean surgical field of any blood
      3. Flat matricectomy electrode (coated on one side)
        1. Place under nail fold (teflon side facing up)
      4. Apply cautery to each exposed area
        1. Set current to 2 (20 W) of coagulation
        2. Apply current for 5 seconds
        3. Allow to cool for 15 seconds
        4. Repeat application of 5 seconds of current
  5. Technique: Dressing
    1. Apply antibiotic ointment
    2. Apply gauze and tube pressure dressing
  6. Management: Home Instructions
    1. Keep foot elevated for first 24 hours
    2. Change dressing in 24 hours
    3. Consider daily antibiotic ointment (e.g. Bacitracin) until heeled
    4. Water exposure is controversial
      1. Some recommend only showering, but no soakings
      2. Others soak foot in warm soapy water 2-4 times daily for 4-7 days
    5. Avoid Trauma to toe for first 2 weeks
      1. Wear loose-fitting shoes
      2. Avoid Running, jumping or other potential injury
    6. Observe for signs of infection (Paronychia)
  7. References
    1. Mandracchia (July, 1998) Hospital Medicine, p. 36-43
    2. Peggs in Pfenninger (1994) Procedures, Mosby, p. 28-43
    3. Heidelbaugh (2009) Am Fam Physician 79(4): 303-12 [PubMed]
    4. Zuber (2002) Am Fam Physician 65(2):2547-58 [PubMed]

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