The Third Ingrown Toenail This Year: Partial Nail Avulsion With Phenol Matrixectomy for a 19-Year-Old, and When the Same Toe Should Go to Podiatry Instead
[Student Name]
University of Phoenix
NRP/571: Advanced Health Assessment II and Clinical Procedures
Week 7 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Mr. J., a 19-year-old college soccer player, has pain, redness and swelling along the lateral edge of his right great toenail for two weeks, his third episode this year. Previous episodes were treated with warm soaks and a course of oral antibiotics. On examination, the lateral nail fold is swollen with granulation tissue and a small amount of drainage, without spreading cellulitis. He has no diabetes or circulation problems. Because there is no cellulitis or abscess beyond the nail fold, the IDSA guidance on skin infections does not call for systemic antibiotics here; drainage and removal of the cause are the treatment (Stevens et al., 2014). This paper describes the procedure and referral considerations.
Staging
Ingrown toenails are often staged by severity: mild with redness and swelling, moderate with drainage and infection and severe with granulation tissue and hypertrophy of the nail fold. Mr. J. has a moderate to severe ingrown nail. Park and Singh (2012) describe conservative care for mild cases and partial nail avulsion, often with chemical matrixectomy, for moderate to severe or recurrent cases.
The Evidence
A Cochrane review of 24 studies involving 2,826 participants found that surgical interventions were more effective than nonsurgical interventions in preventing recurrence, and that adding phenol to partial nail avulsion was probably more effective in preventing recurrence and regrowth than avulsion alone (Eekhof et al., 2012). With three episodes this year, Mr. J. needs a treatment that prevents recurrence.
Soaking and antibiotics treated each episode; only removing the edge and its root will prevent the next one.
Why Antibiotics Alone Failed
Antibiotics treat surrounding infection but do not remove the nail edge embedded in the skin, which is the cause. Park and Singh (2012) note that oral antibiotics are often unnecessary when the nail edge is removed, since removal allows the inflammation to resolve.
Consent
Before starting, I describe what I will do and why, then the possible problems, including pain, infection, delayed healing and a small chance of regrowth, and the alternatives, including referral to podiatry. He consents.
The Procedure
After cleaning the toe, I perform a digital block at the base of the great toe with 1% lidocaine without epinephrine, waiting until the toe is numb, and apply a tourniquet at the base. Using a nail elevator, I free the lateral quarter of the nail from the nail bed and cut it longitudinally with nail splitters back to the proximal nail fold, then remove the strip with a hemostat, including the portion under the fold. I curette the granulation tissue. I apply 88% phenol to the exposed lateral matrix with a cotton-tipped applicator for about 30 seconds in three applications, then irrigate with alcohol. The tourniquet is removed, and I apply antibiotic ointment and a bulky dressing.
Why a Digital Block and Tourniquet
A digital block anesthetizes the whole toe with a small volume, allowing painless nail removal and phenol application. Plain lidocaine is used by tradition in digits, although epinephrine is now considered safe in healthy digits by many clinicians. A tourniquet keeps the field bloodless, which matters because blood dilutes phenol and reduces its effect on the matrix.
Why Only Part of the Nail
Removing only the ingrown edge preserves most of the nail, giving a better cosmetic and functional result. Total nail removal is reserved for severe or bilateral involvement or deformed nails.
Why Phenol
Phenol destroys the matrix cells that would regrow the removed edge and also has antiseptic and anesthetic properties. The Cochrane review found that adding phenol probably reduces recurrence compared with avulsion alone (Eekhof et al., 2012). Its main drawback is prolonged drainage while the chemical burn heals.
What Happens to the Nail
After healing, the nail is slightly narrower on the treated side. I show Mr. J. a diagram so he knows what to expect, since athletes sometimes worry about appearance.
Aftercare
Elevate the foot for the first day, change the dressing daily and begin soaks after 24 to 48 hours. Drainage for two to four weeks is expected after phenol. He should wear open or roomy shoes and avoid soccer for about one to two weeks, until pain allows.
Prevention
Cutting nails straight across, not too short, wearing shoes that fit well and managing sweating help prevent recurrence in other toes.
When to Refer Instead
The same procedure would not be done in the office for everyone. Referral to podiatry is appropriate for patients with peripheral arterial disease or poor circulation, diabetes with neuropathy or poor control, immune suppression, a severe infection with spreading cellulitis or abscess, bilateral or complex nail deformity or failure of previous matrixectomy. In these patients, healing is impaired and complications can be serious.
Sports Considerations
For a soccer player, tight cleats and repeated toe impact contribute to ingrown nails. I suggest checking cleat fit, trimming nails straight across before the season and keeping feet dry.
When the Nail Regrows
If the edge regrows despite phenol, a repeat matrixectomy or referral to podiatry for a more extensive procedure can be considered. Documenting the portion removed helps plan any future procedure.
Healing Expectations
The fold should look markedly better within two weeks and heal fully in four to six weeks. Persistent redness, increasing pain or pus after the first week may indicate infection and should prompt a visit.
Return to Play
He can return to soccer when he can wear a cleat without significant pain, usually after one to two weeks, protecting the toe with a small dressing.
Why Not Just Lift the Nail Edge
For mild ingrown nails, placing cotton or dental floss under the edge can lift it from the skin as it grows out. With granulation tissue and three episodes, this conservative approach has already had its chance, and the Cochrane evidence favors surgical treatment for recurrence (Eekhof et al., 2012).
Pain After the Block Wears Off
The toe may ache for a day or two after the anesthetic wears off. Acetaminophen or ibuprofen and keeping the foot elevated usually control it; severe or throbbing pain should prompt a call.
Socks and Hygiene
Clean, dry, breathable socks and daily washing reduce infection risk during healing and help prevent future episodes.
Documentation
The note records indication, staging, consent, anesthesia, tourniquet time, portion of nail removed, phenol concentration and application time, dressing and instructions.
Follow-Up
Wound check in one week, then as needed until healed.
Conclusion
Mr. J.'s third ingrown toenail with granulation tissue called for a procedure that prevents recurrence rather than another round of soaks and antibiotics. Cochrane evidence supports partial nail avulsion with phenol, which was performed with a digital block and careful technique. For patients with diabetes, poor circulation or other risks, the same problem calls for referral, and the note states why office care was appropriate for him.
References
Eekhof, J. A. H., Van Wijk, B., Knuistingh Neven, A., & van der Wouden, J. C. (2012). Interventions for ingrowing toenails. Cochrane Database of Systematic Reviews, 2012(4), Article CD001541. https://doi.org/10.1002/14651858.CD001541.pub3
Park, D.-H., & Singh, D. (2012). The management of ingrowing toenails. BMJ, 344, Article e2089. https://doi.org/10.1136/bmj.e2089
Stevens, D. L., Bisno, A. L., Chambers, H. F., Dellinger, E. P., Goldstein, E. J. C., Gorbach, S. L., Hirschmann, J. V., Kaplan, S. L., Montoya, J. G., & Wade, J. C. (2014). Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 59(2), e10-e52. https://doi.org/10.1093/cid/ciu296
How this NRP 571 Week 7 example is structured
The NRP/571 Week 7 work usually addresses other office procedures and when to refer. This paper uses a common problem to show how evidence guides choosing a procedure, how the procedure is done and how specific patient factors change the setting of care. Students search this week as NRP 571 Week 7, NRP571 Wk 7 or NRP/571 Wk 7; all three are the same assignment.
NRP/571 Week 7 questions, answered
What does NRP/571 Week 7 usually ask for?
Many sections ask students to describe additional office procedures, their indications and technique, and the criteria for referral to a specialist.
What is a phenol matrixectomy?
Application of phenol to the nail matrix after removing the ingrown edge of the nail, destroying the matrix in that area so the edge does not regrow.
When should an ingrown toenail be referred?
When the patient has poor circulation, diabetes with neuropathy, immune compromise, severe infection or when office treatment has failed, podiatry or surgical referral is usually appropriate.
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