Long-Term Results of Nail Brace Application in Diabetic
Patients with Ingrown Nails
F
ATMAG
U¨ LRUE
RDOGAN, MD, MPH
,
ANDG
U¨ RBU¨ZE
RDOGAN, MD
yBACKGROUND Ingrown toe nail is a common foot problem; however, there are limited data concerning the treatment options for diabetic patients.
OBJECTIVE Because of the special attention given to avoidance of infection and ulceration of the foot in diabetics, we applied a new, simple nail device as a treatment option without any systemic treatment or surgical intervention.
METHODS AND MATERIALS We applied braces to 21 diabetic patients with ingrown toe nails. All had severe pain, erythema, and edema without suppuration or granulation tissue formation. Braces were applied until all the symptoms are cleared. We followed the patients for 2 years for the recurrence of symptoms and signs.
RESULTS All patients had immediate relief of symptoms once the brace was applied. After the dis-location of braces, 15 of 21 patients did not have any recurrences for 2 years. Six patients had recurrence of pain and ingrown nail and were willing to use the brace once more instead of having any operations. CONCLUSION Nail brace application is a safe, simple, and inexpensive treatment option for diabetic patients with ingrown toe nails. Although there may be recurrences, patients are willing to use it for a second time as it is simple and pain free.
Dr F. Gu¨lru Erdogan holds a patent for the device described within.
I
ngrown toe nail is one of the dermatologic abnormalities that can be seen in diabetic patients and can sometimes be complicated with infection and granulation tissue formation. Foot lesions in the diabetic population deserve special attention. In previous studies, ingrown nail was cited among the risk factors to develop foot lesions in diabetics.1 There are limited data concerning the treatment of ingrown nail in diabetics. Although some surgical methods were shown to be effective, they may sometimes cause complications as well.2,3We de-cided to apply a new simple nail brace for diabetic patients with ingrown toe nails and follow them for the relief and recurrence of symptoms.1,4,5Materials and Methods
Twenty-one non–insulin-dependent diabetic patients with the complaint of pain, erythema, and edema on
the nail side were enrolled to the study at the Ankara University School of Medicine. They all refused to have any surgical intervention and accepted using the nail brace.
First we checked the presence of peripheral neuropathy with a biothesiometer (Bio-Medical Instrument Co., Newbury, OH). We then applied a small nail brace with two hooklike projections on the sides and a dental string in the middle pulling two sides upward (Figure 1). The apparatus was fixed by hypoallergenic tape paying attention that the tape was touching only the nail plate but not to adjacent skin. No local anesthesia or systemic or topical treatment was given. Immedi-ately after the application of the nail brace, patients were asked to walk and stand on their toe tips barefoot to see whether they had any complaint left (Figure 2). Patients were followed once a month. During the monthly controls the nail apparatus was first
&2007 by the American Society for Dermatologic Surgery, Inc. Published by Blackwell Publishing
ISSN: 1076-0512 Dermatol Surg 2008;34:84–87 DOI: 10.1111/j.1524-4725.2007.34013.x
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removed; patients were then checked whether they had any complaint without the brace, and if they did, we applied a new brace. Once their complaints were cleared, treatment was stopped. Patients were fol-lowed until June 2006 and number of recurrences were noted.
Results
We had 21 non–insulin-dependent diabetic patients without peripheral neuropathy. Only 2 had bilateral
involvement whereas 19 had complaint only on one side. Mean duration of their complaints was 3.957 2.82 months.
During the nail brace application, all patients were completely pain free; they continued their daily ac-tivities as usual. Mean duration of nail brace appli-cation was 4.107 2.36 months. Mean duration of follow-up after the cessation of treatment was 27.387 2.77 months.
Fifteen of 21 patients did not have any recurrences after a single course of nail brace application. Mean duration of treatment was 2.837 0.75 months for recurrent cases and 4.607 2.61 months for nonre-current cases. Mean duration of pain free interval for recurrent cases was 2.837 2.14 months (Table 1). Recurrent cases were willing to use the brace once more instead of having any operations.
Conclusion
Foot complications are encountered three to four times more often in diabetic patients than in nondi-abetic controls.6 It is well documented that foot problems and infections in patients with diabetes account for a large fraction of diabetic complications seen in clinical practice, which also result in huge costs for both society and the individual patients.7–9 In contrast, foot complications are the only ones that can be decreased by preventive measures.6–10 Ingrown toenail is one of the skin lesions consid-ered as a risk factor for diabetic foot disease.7Early
Figure 1. Application of nail brace with two hooklike
projec-tions on the sides, and a dental string in the middle pulling the sides of the nail upwards.
Figure 2. Application of nail brace in a diabetic patient with
ingrown toe nail.
TABLE 1. Mean Duration of Complaints and Mean Duration of Application for Recurrent, Nonrecur-rent, and All Patients
Mean duration of complaints (months)7 SD Mean duration of application (months)7 SD Recurrent cases (n = 6) 3.177 1.47 2.837 0.75 Nonrecurrent cases (n = 15) 4.277 3.19 4.607 2.61 All patients (n = 21) 3.957 2.82 4.107 2.36 3 4 : 1 : J A N U A RY 2 0 0 8 8 5 E R D O G A N A N D E R D O G A N
recognition and effective treatment of this condition can result in the prevention of more severe outcomes. Nail brace application is a simple, inexpensive, patient friendly, easy-to-apply treatment option in diabetic patients with ingrown toe nails. Patients continue their daily activities, and no systemic treatment is required. Although many treatment modalities are present for the treatment of ingrown nails, the data on the effectiveness of these tech-niques are sparse.11–18
Nail brace application causes immediate relief of symptoms; by stopping the irritation on the nail side it might also help prevention of infection. Although recurrences may be seen in some patients, which usually occur within the first 6 months after the cessation of the treatment, patients are usually eager to use a repeated course of nail brace application rather than having an operation.
References
1. Litzelman DK, Marriott DJ, Vinicor F. Independent physiological predictors of foot lesions in patients with NIDDM. Diabet Care 1997;20:1273–8.
2. Karabagli V, Kose AA, C¸ etin C. Toe necrosis due to a neglected tourniquet. Plast Reconstr Surg 2005;116:2036–7.
3. Toybenshlak M, Elishoov O, Akopnick I, et al. Major complica-tions of minor surgery; a report of two cases of critical ischaemia unmarked by treatment for grown nails. J Bone Jt Surg Br 2005;87:1681–3.
4. Felton PM, Weaver TD. Phenol and alcohol chemical matricec-tomy in diabetic versus nondiabetic patients. J Am Podiatr Med Assoc 1999;89:410–2.
5. Giacalone VF. Phenol matricectomy in patients with diabetes. J Foot Ankle Surg 1997;36:264–7.
6. Von Ferber L, Kaster I, Hauner H. Medical costs of diabetic complications. Total costs and excess costs by age and type of
treatment results of the German CoDiM study. Exp Clin End-ocrinol Diabetes 2007;115:97–104.
7. Nidal AY, Azmi TA. Diabetic foot disease. Endocr Prac 2006;12:583–92.
8. Giurini JM, Lyons TE. Diabetic foot complications: diagnosis and management. Int J Low Extrem Wounds 2005;4:171–82. 9. Ragnarson TG, Apelquist J. Health-economic consequences
of diabetic foot lesions. Clin Infect Dis 2004;39(Suppl 2): 132–9.
10. Meijer JW, Links TP, Smit AJ, et al. Evaluation of a screening and prevention programme for diabetic foot complications. Prothet Orthot Int 2001;25:13–8.
11. Yang K, Li Y. Treatment of recurrent ingrown great toenail as-sociated with granulation tissue by partial nail avulsion followed by matricectomy with sharpulse carbon dioxide laser. Dermatol Surg 2002;28:419–21.
12. Abby NS, Roni P, Amnon B, Yan P. Modified sleeve method treatment of ingrown toenail. Dermatol Surg 2002;28:852–5. 13. Lazar L, Erez I, Katz S. A conservative treatment for ingrown
toenails in children. Pediatr Surg Int 1999;15:121–2.
14. Kocyigit P, Bostanci S, Ozdemir E, Gurgey E. Sodium hydroxide chemical matricectomy for the treatment of ingrown toenails: comparison of three different application periods. Dermatol Surg 2005;31(7 Pt 1):744–7.
15. Ozawa T, Nose K, Harada T, et al. Partial matricectomy with a CO2laser for ingrown toenail after matrix staining. Dermatol Surg 2005;31:302–5.
16. Serour F. Recurrent ingrown big toenails are efficiently treated by CO2laser. Dermatol Surg 2002;28:509–12.
17. Kim JH, Ko JH, Choi KC, et al. Nail splinting technique for ingrown nails: the therapeutic effects and the proper removal time of the splint. Dermatol Surg 2003;29:745–8.
18. Ozawa T, Yabe T, Ohashi N, et al. A splint for pincer nail surgery: a convenient splinting device made of an aspiration tube. Dermatol surg 2005;31:94–8.
Address correspondence and reprint requests to: Fatma Gu¨lru Erdogan, MD, MPH, Ufuk University School of Medicine, Department of Dermatology Ankara, Turkey. Mevlana Bulvari (Konya Yolu) No: 86-88 06520 Balgat, Ankara, Turkey, or e-mail: [email protected]
COMMENTARY
Ingrown nails are a common problem. We read with interest the two articles on ingrown nail management by Drs Erdogan and Noe¨l in this issue of the Journal. Together, they present variations from the traditional treatment of ingrown nails using partial matricectomy, either with phenol, sodium hydroxide, or wedge resection.
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Erdogan and Erdogan studied 21 non–insulin-dependent diabetic patients with ingrown nails, without suppuration or granulation tissue (Zaias Class I disease). After use of orthonyx (nail brace) splints held by dental floss, all patients experienced immediate pain relief. Fifteen of 21 had no recurrence for 2 years. The treatment involved no anesthesia and minimal discomfort during placement of orthonyx, but re-peated office visits for reapplication. Orthonyx have been used to treat ingrown and pincer nails with mixed long-term results.1–3Unlike pincer nails, where in many cases the pathogenesis involves arthritic-related widening of the matrix,1ingrown nails are more commonly associated with plate malalignment or hypertrophy of the lateral nail fold, use of ill-fitting or narrow-toed shoes, cutting the toenails in a half-circle instead of straight across, and often a combination of multiple factors. Therefore, use of orthonyx to temporarily elevate the lateral plate margins and allowing the acute and subacute inflammation time to subside is more legitimate for ingrown nails than for pincer nails. We think that this use of orthonyx may be one alternative therapy for some patients without advanced disease who decline surgery.
Dr Noe¨l studied 23 patients in whom he excised a ‘‘large volume of soft tissue’’ (presumably nailfold/ nailbed) rather than doing a partial matricectomy. The ingrowing nail spicule was not excised and the matrix left alone. The patients were followed for 12 months. No relapses were noticed. ‘‘The main advantage is complete preservation of the anatomy and function of the nail.’’ This avoids ‘‘a disgraceful and deformed toe.’’ This study involved local anesthesia and a more invasive surgical technique than the orthonyx by Erdogan, but avoided matrix scarring or removal and the resultant plate diminution. Perhaps this technique most elegantly targets patients with predisposing hypertrophic lateral nail folds.
We have utilized various forms of partial matricectomy without causing ‘‘deformed toes,’’ including extensive use of partial matricectomy using phenol. This treatment is well established in the literature as the treatment of choice for ingrown nails.4–7Furthermore, we have not seen prolonged healing times using this procedure.
We applaud these articles for furthering evidence-based medicine on nail surgery. We also commend the follow-up period of at least 1 year. Although no single treatment fits all patients, an understanding of disease pathogenesis may help guide therapy. We would add that it is crucial to emphasize patient education to help prevent recurrence.
C. RALPHDANIELIII, MD Jackson, MS NATHANIELJ. JELLINEK, MD Providence, RI
References
1. Baran R, Haneke E, Richert B. Pincer nails: defiition and surgical treatment. Dermatol Surg 2001;27:261–6.
2. Kim YJ, Ko JH, Choi KC, et al. Nail-splinting technique for in-grown nails: the therapeutic effects and the proper removal time of the splint. Dermatol Surg 2003;29:745–8.
3. Ozawa T, Yabe T, Ohashi N, et al. A splint for pincer nail surgery: a convenient splinting device made of an aspiration tube. Dermatol Surg 2005;31:94–8.
4. Andreassi A, Grimaldi L, D’Aniello C, et al. Segmental phenol-ization for the treatment of ingrowing toenails: a review of 6 years experience. J Dermatol Treat 2004;15:179–81.
5. Rounding C, Hulm S. Surgical treatments for ingrowing toenails. Cochrane Database Syst Rev 2000;CD001541.
6. Rounding C, Bloomfield S. Surgical treatments for ingrowing toe-nails. Cochrane Database Syst Rev 2000;CD001541.
7. Daniel CR III, Iorizzo M, Tosti A, Piraccini BM. Ingrown toenails. Cutis 2006;78:407–8.
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