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Toenail Excision

Before you agree to have toenail excision (toenail removal) performed it is important to know all you can about it.  The information here is a guide to common medical practice. Each hospital and doctor will have slightly different ways of doing things, so you should follow their guidance where it is different from the information given here. Because all patients, conditions and treatments vary it cannot cover everything. Use this information when making your toenail removal treatment choices with your doctors. You should mention any worries you have. Remember that you can ask for more information at any time.
 
 

What is the problem?

You have an ingrowing toenail or a thickened toenail, probably on your big toe. Part, or all of the nail and nail bed may need to be removed.
Toenail excision

What has gone wrong?

Ingrowing toenails press into the skin on one or both sides of the nail. This is because an ingrowing toenail is more curved from side to side, than usual. This “ingrowing” damages the skin folds and infection takes hold, causing pain and swelling. The infection can come and go for months or years.
 
A similar infection can occur if you tear a normal nail or if you injure or damage the skin folds with tight footwear. It can also happen if you have poor circulation to your toes.
 
A thickened nail has a different cause. It is caused by damage to the nail bed, which the nail grows from. This is usually caused by a long-term infection with athlete’s foot fungus. The damage is usually permanent and gets steadily worse.
 
Very rarely, usually in adults, the cause is an overgrowth of bone or a tumour of the skin under the nail.
 
 

The aims

We aim to remove your abnormal nail and usually the nail bed too. If we only remove the nail, an abnormal nail will grow from the nail bed again. The way we do this operation depends on the problem.
 
  • Ingrowing toenail - We need only remove narrow strips of nail bed near the skin folds.
  • Thickened nail - We need to surgically remove the whole of the nail bed with the help of chemicals.
  • Bone overgrowth - We remove the nail and shave the bone smooth again.
  • Tumour - We remove both the nail and the tumour. We send the tumour for examination under the microscope.
Toenail excision 2
 
If your problem is caused by poor circulation to your toe you may need treatment to improve the blood flow.
 

The benefits

The benefits after recovery from the operation also depend on the problem.
 
  • Ingrowing toenail - The bouts of infection should stop. Your nail will be narrower, but should otherwise look normal.
  • Thickened nail - After treatment for a thickened nail your toe should be pain-free with smooth skin growing where the nail used to be.
  • Bone overgrowth - The swelling should go, but your nail may not be as smooth as normal.
  • Tumour - This should be gone but you will find out more at the follow-up clinic.  Depending on the results, more treatment may be planned.
 
 

Are there any alternatives?

 
  • Ingrowing toenails - Useful first treatments include antibiotics, twice daily foot washing and looser footwear. Clipping the nails square-ended rather than round-ended or pushing cotton wool under the nail end may also help. Cutting a V-shaped piece out of the end of the nail does not work. Simple removal of the nail does not usually work.
  • Thickened nails - Long-term antibiotic treatment to control athlete’s foot may lead to some improvement. Chemical treatment alone may be as good as surgical removal plus chemical treatment. If we only remove the nail it will grow back the same.
  • Bone overgrowth or tumour - Surgery is usually the only option to get rid of these.
 

What if you do nothing?

 
  • Ingrowing toenails - Ingrowing toenails often get better by themselves. If you are elderly or diabetic and have ingrowing toenails due to poor circulation then serious infection may set in if you do nothing. Urgent treatment to improve the circulation could be missed.
  • Thickened nails - You may be able to control these by clipping and filing. This may require strong clippers and files, as thickened nails often get worse over time.
  • Bone overgrowth - This may continue to enlarge and may damage the nail bed.
  • Tumour - If this is a malignant cancer it could spread to other parts of your body. Some under nail tumours cause great pain, if not removed.
 

Who should have it done?

If your ingrowing toenail is no better after a month or so of simple treatments or you have bouts of pain and swelling you should consider an operation.
 

Who should not have it done?

If you have poor circulation you should not have your nail bed removed. An operation could lead to serious infection and even loss of the toe or leg. If poor circulation has caused an ingrowing toenail then it will often heal after treatment to improve the circulation.
 
Author: Mr Michael Edwards FRCSEng FRCSEd. Consultant general surgeon.
© Dumas Ltd 2006
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