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Ingrowing
toe nail or Unguis Incarnatus is an acquired disorder affecting commonly
the great toe.
The nail curls in and digs into the soft tissues of the toe.
We present a case of 18 yr. old female who presented to us with an ingrowing
toe nail of the right great toe. The anterior border of the nail dipped
into the soft tissues of the great toe and was jetting out of the plantar
aspect of the right great toe. The nail was growing, though at an unusual
location, and the patient used to clip it regularly until the infection
in the nail fold brought the patient to us. |
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INTRODUCTION |
In
growing toe nail also called as the embedded toe or unguis incarnates
is an acquired condition of usually the great toe. It is a common problem
of unknown aetiology. The great toe is most commonly involved. The lateral
side is involved more commonly than the medial side. Here we present
a case of an 18 year old female, where the anterior side is involved
and has dipped into the tissues of the right great toe resulting in
the nail jetting out of the plantar surface of the right great toe,
an unusual presentation. We have not found any mention of a similar
presentation in the literature. |
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CASE
REPORT |
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DISCUSSION |
Ingrowing
toe nail also called unguis incarnatus also called embedded toe nail
is an acquired condition of the toe commonly the great toe and more
commonly involving the lateral side than the medial side resulting in
a painful condition that may get infected. It can rarely be congenital.1
The aetiology if ingrowing toe nail is unknown. The factors said to
cause are wearing tight shoes, cutting the nails short and convex, trauma
and heredity. A family history in the first and second degree relatives
may be evident. Indinavir used in AIDS patients has been shown to cause
ingrowing toe nail.2
The pathophysiology of this condition is a foreign body reaction. The
nail bed is compressed by the nail and then the nail enters the cuticle.
The keratinaceous material of the nail in the flesh of the toe sets
up a foreign body reaction.
The complaints of the patient are the pain due to the nail digging into
the cuticle initially and later the infection of the overhanging nail
fold. If infected there may be evidence of discharge, oedema, erythema
and local warmth are usually present. Radiography (X rays) should be
considered when it is necessary to rule out osteomyelitis or in the
situation of associated trauma to rule out toe fractures.3 This disorder
is rare in perambulatory stages.
Conservative management includes, softening the nail with warm water
and rolling the edge out to allow the elevation of the nail. Further
occurrence can be prevented by using shoes which have wide toe box and
avoidance of the above causative factors. When the conservative measures
fail partial removal of nail under appropriate anaesthesia has to be
undertaken. After elevating, the in growing portion of the nail is rolled
towards the midline of the toe exposing the germinal end of the nail.
The ingrowing portion is then excised. Antibiotics and analgesics are
prescribed if needed.4 Appropriate preventive measures are advice to
prevent recurrence.
Various studies have shown chemical matricectomy with phenol to be equally
efficacious.5 Other treatments described include nail surgery with CO2
laser6 and Sleeve method7 where a plastic tube is inserted under the
nail
.
Interventions to prevent recurrence have been described and include
Silicon gel sheeting8 and Splinting of the nail with a flexible tube.9 |
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REFERENCES |
| 1. |
Piraccini
BM, Parente GL, Varotti E, Tosti A. Congenital hypertrophy of
the lateral nail folds of the hallux: clinical features. Pediatr
Dermatol 2000;17(5):348-51. |
| 2. |
AIDS.
Ingrown toenail and indinavir: case-control study demonstrates
strong relationship. 1999 Oct 22; 13(15):2181-2. |
| 3. |
Cox
HA, Jones RO. Direct extension osteomyelitis secondary to chronic
onychocryptosis. Three case reports. J Am Podiatr Med Assoc
1995; 85(6):321. 9. |
| 4. |
Reyzelman
AM, Trombello KA, Vayser DJ, Armstrong DG, Harkless LB. Are
antibiotics necessary in the treatment of locally infected ingrown
toenails? Arch Fam Med 2000; 9(9):930-2. |
| 5. |
Partial matrix excision or segmental phenolization for ingrowing
toenails. Arch Surg 2002;137(3):320-5. |
| 6. |
Lin
YC, Su HY. A surgical approach to ingrown nail: partial matricectomy
using CO2 laser. Gerritsma-Bleeker CL, Klaase JM, Geelkerken
RH, Hermans J, van Det RJ. Dermatol Surg 2002; 28(7): 578-80 |
| 7. |
Abby
NS, Roni P, Amnon B, Yan P. Modified sleeve method treatment
of ingrown toenail. Dermatol Surg 2002; 28(9): 852-5. |
| 8. |
Aksakal
AB, Ozsoy E, Gurer M. Silicone gel sheeting for the management
and prevention of onychocryptosis. Dermatol Surg 2003; 29(3):
261. |
| 9. |
Gupta
S, Sahoo B, Kumar B. Treating ingrown toenails by nail splinting
with a flexible tube: an Indian. experience. J Dermatol 2001;
28(9): 485. |
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A
CURE FOR CARDIOVASCULAR DISEASE?
Todays BMJ contains one of the boldest claims for a new intervention.
A single pill containing aspirin, a statin, three blood pressure
lowering agents in half dose, and folic acid is provided to
people with vascular disease and those aged over 55 years.
They synthesise an enormous amount of information (including
over 750 trials with 4000,000 participants) to estimate that
the pill would reduce heart disease and risk of stroke by
over 80%, and fatal side effects in less than one in 10,000
users.
Will the benefits be so great? Lowering cholesterol concentrations
that are above 4.0 mmol/l and blood pressure values above
120/80 mm Hg is likely to confer benefit even though many
early trials and much clinical practice focuses on people
with hypercholesterolaemia or hypertension. Wald and Law argue
convincingly that three blood pressure lowering agents at
half the standard dose are the best way to achieve large reductions
in blood pressure.
Will the side effects be so low? Contrary to many perceptions,
these drugs have remarkably few side effects.
To whom should this new intervention be offered? Every person
over the age of 55 although this debate should not detract
from the size and certainty of net benefits in those with
vascular disease.
A wider debate is needed across society about extensive use
of preventive medications, especially among people without
symptomatic disease. In many countries already take natural
supplement pills regularly (mostly multivitamins with uncertain
benefits, or antioxidants, now known to have no important
benefits for major diseases)
.
Antony Rodgers, Clinical Trials Research Unit, University
of Auckland. BMJ 2003; 326 : 1408
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