Introduction

Ingrown nail, also known as onychocryptosis, is a common nail disorder of the big toes, characterized by pain, swelling, and discharge. It carries a significant negative impact on the quality of life.[12] Majority of grade 1 cases can be managed conservatively that includes anti-inflammatory drugs with or without antibiotics, packing, taping, and nail braces. However, significant proportion of patients with grade 2 severity, especially with recurrent episodes and those with grades 3 and 4 require surgical measures.[3] One of the most common surgical interventions is partial nail avulsion with chemical matricectomy with 88% phenol. In this pilot study, we have attempted to study the efficacy and safety of partial nail avulsion followed by matricectomy with radio-frequency (RF) ablation in grade 2 ingrown toenails in Indian population.

Materials and Methods

Surgical technique

1. The concerned digit was cleaned with povidone– iodine.

2. Proximal digital block was administered with 1% lidocaine, and finger tourniquet was applied to attain a clean bloodless field.

3. Partial nail avulsion was performed as per the standard protocol.[12] On the affected side, the nail plate was separated from the nail bed in a controlled manner using nail elevator, starting from the edge.

4. A 2–4 mm longitudinal strip of the nail plate was removed along with the lateral horn.

5. The lateral horn of the matrix was ablated by RF using a tungsten electrode that was flat and bent at an angle as shown in Figure 1. The electrode was placed for 3–5s and it was repeated two to three times.

6. Tourniquet was released and a bulky dressing was carried out for the digit using liberal amount of antibiotic cream.

7. In addition to general precautions, the patients were prescribed pain killers and a course of broad-spectrum antibiotics.

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Figure 1

Radio-frequency ablation for partial matricectomy using a tungsten electrode flat and bent at an angle

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Results

Eight adult patients were recruited for the study with an involvement of total 10 nails. Of these, six were males and two were females and their age ranged from 18 to 42 years. Two patients had bilateral toenail involvement, whereas the rest showed unilateral involvement only. All patients had grade 2 ingrown nail, that is, the presence of inflammation, pain, and mild granulation tissue. They were treated with a conservative approach, which brought no relief to any of them. Patients were screened for diabetes and coagulation disorders. History of pacemaker insertion was taken as this is an absolute contraindication for RF procedures.

On follow-up, the average number of days required for postprocedural healing was 7.5 days (range, 5–8 days) as shown in Figures 2 and 3. Significant improvement was observed in terms of erythema, pain as well as swelling within 5 days of surgery. Postoperative ooze was minimal on day 2 (grade 1 in eight and grade 2 in two nails) and absent (grade 0) on second visit, that is, by day 4 in all the patients (100%). Postoperative pain was minimal. Mean VAS score for pain on day 0, 2, and 4 was 4.5, 2, and 0, respectively. All the patients were pain free by the second visit (day 4).

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Figure 2

Pre- and postoperative (day14) clinical picture showing quick healing and grade 0 drainage

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Figure 3

Pre- and postoperative (day14) clinical picture showing grade 0 drainage and fast tissue recovery

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Complications such as prolonged ooze/discharge or secondary infection were encountered in none of the cases. All the patients were ambulatory by day 2. No recurrence was noticed in any of them in 3–6 months.

Discussion

Ingrown nail can be a very painful condition and can negatively affect the daily activities of the patient. Management can be conservative or surgical, which depends on the grade of the disease.[12] It has been classified into four grades according to Mozena classification. Grade 1 requires conservative approach. Grade 2 often requires partial matricectomy, whereas for grade 3 and 4, treatment is always surgical intervention, namely partial nail plate avulsion with matricectomy or wedge resection.[3]

Matricectomy can be performed by either chemical or mechanical destruction. Chemical matricectomy is usually performed with the help of phenol (88%), trichloroacetic acid (100%), and sodium hydroxide (10%).[4] Though chemical matricectomy is a simple and inexpensive technique, healing time is relatively longer. In addition, there can be unpredictable collateral tissue damage. There is also prolonged drainage resulting from epidermal slough caused by the chemical burn and the possible infection.[456] In a study comparing the efficacy of 88% phenol and 10% sodium hydroxide, median duration of postoperative pain was reported to be 16.25 and 7.92 days, respectively. The postoperative discharge continued for a median period of 18.13 and 15.42 days and the healing time was 15.63 and 7.50 days, respectively.[7] On the contrary, our study showed a shorter duration of both postoperative pain and swelling (5 days) and postoperative healing (7.5 days). In addition, postoperative ooze was markedly less in our patients (minimal/absent by day 4).

Matricectomy by surgical excision has a low recurrence rate, but it can be tedious and a lengthy procedure. It is also associated with higher postoperative pain and prolonged drainage. Mechanical matricectomy can also be performed with the help of carbon dioxide (CO₂) laser, and cryotherapy has been reported to offer more effective and selective destruction of the nail matrix than chemical matricectomy but it is very expensive and requires technical expertise. High cost of laser, prolonged healing time, and poor cosmetic outcome limit the use of this technique.[4589]

RF ablation of the matrix horn is a faster, less painful option that causes selective tissue damage. There is less lateral heat spread and tissue damage with better control. Recurrence rate is lower and healing is faster with this technique. This poor man’s laser has shown to be more effective and versatile in comparison to the CO₂ laser.[410]

In our study, all 10 nails treated with partial nail avulsion with matricectomy by radio-frequency ablation showed faster healing within a week time. There was a significant reduction in ooze, pain, and swelling. Adverse effects such as postoperative pain and drainage and secondary infections were nil. Recurrence was not observed in any of the patients after 3–5 months follow-up. Thus, RF ablation may be considered as a relatively inexpensive, safe, and effective alternative for nail matricectomy for the treatment of ingrown toenail.

Conclusion

Matricectomy by radio-frequency ablation is a safe and effective method of partial matricectomy with lower complications and recurrence rate. It can therefore be used as an alternative method in surgical management of ingrown nail.