Management of lateral nail spicules: A distressing sequela of improper toenail surgery

INTRODUCTION

Ingrown toenail or onychocryptosis is a common condition, especially in young adults. It occurs due to a painful and improper growth of nail tissue into the lateral nail fold. Commonly affecting the great toes, it tends to be aggravated with occlusive footwear, improper nail trimming, and an active lifestyle.¹ Severe cases require surgical intervention. Lateral partial nail avulsion combined with lateral chemical matricectomy is the most commonly performed procedure for ingrown toenails. However, a rare but unfortunate sequela of ingrown toenail surgery could be the regrowth of lateral nail spicules. This occurs in cases where the lateral horn matricectomy is incomplete or unsuccessful, and attention has not been paid to the lateral most extent of the nail matrix. The partially destroyed matrix subsequently gives rise to nail spicules. These spicules become symptomatic as they continue to grow, forming an epithelialized tract till they emerge through the lateral nail fold. They are often very painful, unyielding to conservative measures, and need surgical resection.²

We describe two patients with nail spicules occurring after improper or inadequate ingrown toenail surgeries. Their surgical management as well as preventive measures are highlighted.

CASE REPORT

Case 2

A 35-year-old obese male presented with complete absence of bilateral great toenails with accompanying painful swellings at the base of the nails for the past 6 months. He gave a history of multiple surgeries over the past 5 years performed at various centers in his town, for recurrent ingrown toenails. Details of the surgeries done were unavailable.

On examination, there was bilateral anonychia with scarring of the proximal nail fold and nail bed. Granulation tissue was seen over the proximal part of the bilateral nail folds with spicules of approximately 1 × 1 × 1 cm. These were present over the base of lateral nail folds of the right great toe bilaterally and the medial aspect of the left great toe [Figure 1b]. These were extremely tender on palpation and associated with surrounding erythema.

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Figure 1: (a) Clinical photograph of a 23-year-old male patient showing nail plate hyperkeratosis with a nail spicule located medially at the junction of the lateral and proximal nail folds (red arrow). (b) Clinical photograph of a 35-year-old male patient demonstrating bilateral great toenail anonychia. Nail spicules are visible at the junction of the proximal and lateral nail folds bilaterally on the right great toenail and along the medial aspect of the left great toenail (red arrows).

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Both patients were initially managed conservatively with analgesics and clipping of the spicules. However, owing to a lack of response, a surgical route was opted for. Both patients (3 involved nails with 4 spicules) underwent spiculectomy (complete surgical resection of the nail spicule) with chemical matricectomy (88% phenol). This was achieved by exposing the canal from which the spicule was arising [Figure 2a] with the help of an appropriately sized nail spatula, followed by avulsion of the embedded spicule, after loosening its attachment to underlying matrix [Figure 2b]. Thereafter, the exposed ectopic matrix remnant giving rise to the spicule was chemically cauterized (matricectomy) using 88% phenol with a contact period of 1 min, so as to prevent recurrence [Figure 2c]. The post-operative course was uneventful, with complete re-epithelialization of the wound within 4 weeks. Case 1 reported an improvement in symptoms from a visual analog acale (VAS) score of 8 at presentation to a VAS score of 2 at 4-week follow-up. Similarly, case 2 reported an improvement in VAS score from 7 at presentation to 2 at 4-week follow-up. Both patients were followed up regularly for 1 year. Case 2 developed recurrence after 6 months in one of the treated sides, which was dealt with in a similar fashion. No recurrence has been recorded thereafter [Figure 3].

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Figure 2: Sequential steps of surgical spiculectomy with chemical matricectomy. (a) Dissection of the nail spicule from the lateral nail fold. (b) Complete avulsion of the nail spicule (spiculectomy). (c) Chemical cauterization of the exposed matrix using 88% phenol (chemical matricectomy).

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Figure 3: Post-operative clinical image at 3-month follow-up showing complete re-epithelialization of the lateral nail fold with marked reduction in local inflammation.

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DISCUSSION

Lateral nail spicules are a rare but distressing sequela of improper or inadequate nail surgeries. Iatrogenic nail spicules have been described after lateral longitudinal nail biopsy, as well as ingrown nail surgery. The condition is associated with severe pain as the spicule produced from the ectopic nail matrix is distorted in architecture and grows vertically through the nail fold soft tissue, harpooning the soft tissue. It also lacks any attachment to the nail bed.³ It is resistant to conservative measures including various nail softening keratolytics hence needs to be managed surgically.

Any nail surgery should have the aim of achieving an optimal balance between correction of the disease or deformity and preservation of the normal nail structure and appearance. This is especially important during toenail procedures. A thorough understanding of nail anatomy, particularly the location and extent of the nail matrix, including its lateral horns, is essential to ensure a complete removal of the offending portion while maintaining the integrity of the remaining matrix. This not only prevents recurrence of ingrown nails but also allows for normal nail growth. Although the details of the surgeries done previously for both our patients were not known, it was evident that the lateral most extent of the matrix horns had not been dealt with optimally, leading to the appearance of spicules. The surgical correction of ingrown nail done in the second case was particularly undesirable as the patient had lost both his great toenails, even though the spicules kept him symptomatic.

Surgical spiculectomy, involving avulsion of the spicule, followed by chemical matricectomy of the exposed matrix, is essential to prevent recurrence of spicules.³ Other methods which could be adopted include a wedge resection of the spicule with underlying matrix, followed by primary closure, or radiofrequency/laser ablation of the matrix after spicule avulsion.⁴ Both 10% sodium hydroxide and 100% trichloroacetic acid have also been successfully used for chemical matricectomy; however, 88% phenol with an average contact time of 1 min has been found to be comparatively more effective with low recurrence rates.^5,6

Surgical intervention remains the mainstay of management for ingrown toenails. However, recurrence and complications are unfortunately common, with recurrence rates reported up to 21–24%, especially with incomplete matricectomy.⁷ Our report emphasizes the need for these procedures to be performed by trained dermatology professionals well-versed with the unique nail anatomy and nail surgery techniques. This is essential to avoid disfigurement or poor cosmetic outcomes. Equally important are proper patient counseling regarding footwear and nail-trimming practices and regular post-operative follow-up to prevent recurrence or secondary complications.

CONCLUSION

Nail spicules are an unfortunate but avoidable outcome of improperly done ingrown nail surgery. Meticulous spiculectomy with targeted chemical matricectomy allows complete removal of the offending nail fragment while minimizing recurrence, providing effective symptomatic relief with maximal preservation of surrounding nail anatomy, thereby ensuring satisfactory cosmetic outcomes.