FootCare Update Expert care from professionals who care.

Volume III, No. 6; Revised Winter, 2006 Patients and their Physicians always benefit when.... DPM’s provide a simple, permanent solution to correct painful or infected ingrown nails. normal skin flora and setting up a ail structure (an inherited char- nidus for infection. acteristic), combined with nor- N 3) Infection (Pyogenic Granuloma) mal shoe gear, is the source of identifies reactive inflammatory tis- ingrown nail pain and/or infection. sue, the result of indwelling of the “Contrary to popular belief, ingrown source of irritation (the nail plate). nails are not a product of incorrect Over 99% of all hypertrophic tissue nail cutting,” said Kenneth Leavitt, identified as pyogenic granuloma is D.P.M., of Brookline, MA. benign and will atrophy upon removal The prevalence of ingrown nails is of the offending nail plate and resolu- highest when individuals wear shoes, tion of the infection with antibiotics. regardless of race, gender or country Pre-Op: Typical incurved nail plate bor- Very rarely will a chronic granuloma of origin. der (left) with infection. become basal or squamous cell carci- The painful or infected ingrown noma. “Reconstruction of chronic nail condition usually affects the great done on each of his great toes. hypertrophic tissue is rarely neces- toe, but also can affect lesser digits. Avulsion does resolve the problem temporarily, but the nail always grows sary,” Leavitt said. Traditional Treatment Ineffective back thicker and more incurvated, due Quick Surgery Best Treatment Ingrown nail treatment, sadly, is to trauma incurred to the nail matrix. for 95% of Patients still anecdotal throughout most of the Removing the offending portion of world, according to Dr. Leavitt. The Progressive Stages of Pathology nail and deadening the matrix to per- most common procedures or Three stages define the progression manently prevent the nail from grow- approaches, seemingly are those that of ingrown nails. ing back works best in 95% of are most prone to failure, including: 1) Curved nail (Onchocryptosis) is patients. They can be treated without • Soaking and systemic antibiotic the inherited condition describing an pain, both before treatment of the infection with no incurvated nail and after the 15 surgical intervention . plate border which “My own procedure really minute procedure, • Avulsion of the entire nail plate. may or may not which is normally “Since the curvature of the nail manifest pain was simple, painless and plate border is the problem, no when contact is permanent. I appreciate the performed conve- amount of cutting V’s in the center of made with shoe need for skilled specialists in niently in the the nail plate or routine palliative care gear. this area.” - Michael Bader, M.D. office. will change the shape of the nail,” 2) Penetration Leavitt said. Addressing the nail (Pyogenic Rarely does the entire nail plate “root” or matrix proximally is the Paronychia) occurs when the curved need to be removed unless there is the only solution, according to this spe- nail border has broken the surround- presence of ascending cellulitis, gross cialist, who has had the procedure ing epidermal barrier, introducing localized granulomatous infection,

Kenneth M. Leavitt, DPM MEDICINE & RECONSTRUCTIVE SURGERY OF THE FOOT Doctor of Podiatric Medicine Fellow, American College of Foot & Ankle Surgeons Diplomate, American Board of Podiatric Surgery, Certified in Foot Surgery FootCare Update

Ingrown Nails (continued) Tips to Physicians about nail-related sinus tract or osteomyelitis. infections and pre-existing complications 15 Minute, Painless Procedure Systemic treatment of infections is a judgment call, but the following The injection is usually painless. rule always applies: Systemic antibiotic therapy without removing the It takes place at the base of the digit, offending nail plate will fail most of the time. A very localized acute not at the site of the infection or near infection of one week or less will almost always resolve with localized the nail lip. Approximately 3.0 ccs of care after removal of the nail plate, without the need for systemic antiobi- a mixture of Xylocaine and Marcaine otic therapy. without Epinephrine is sufficient. Hemostasis is required, usually ....Bacteriology: The most common infection by far is with a digital tourniquet and hemo- Staphylococcus Epidermidis or Staphylococcus Aureus. E-Coli and stats. The offending nail lip(s) is Klebsiella infections run a distant second in healthy patients. removed, the operative site is dried Pseudomonas infections are rare, except for compromised hosts. In com- promised hosts such as those with diabetes, vascular disease immuno- supression, HIV, etc., the susceptibility to more resistant pathogens increases. Given the resistance spectrum of the most common pathogens, the Penicillins, such as Amoxicillin, generally are useless in treating these infections. The drugs of choice are the Cephalosporins, Clindamycin and Erythromycin. All patients with mitral valve prolapse and patients with joint prostheses should be prophylaxed prior to and after nail plate surgery, regardless of the presence or absence of infection. The usual prophylaxis regime in patients who are not Cephalosporin allergic, is 2 grams of Duricef one to two hours pre-operatively and one gram approximately 12 hours post - operatively. Long-term treatment for advanced cellulitis would be 7-10 days of antibiotic therapy, especially in patients with mitral valve prolapse Typical Post Op: Offending nail lip (left) or joint prostheses. was removed and the nail matrix and exposed groove were deadened to pre- ...Factors to Rule Out Prior to Surgery: A complete history and vent recurrence. physical examination of the lower extremity is critical in order to rule out with gauze and the nail matrix region other factors causing pain or to be considered prior to surgical interven- and entire exposed nail groove are tion. These factors include: phenolized, then flushed with a. Vascular disease with resultant ischemic pain. Isopropyl Alcohol. (Some practition- b. Uncontrolled diabetes in the presence or absence of adequate ers prefer to use carbon dioxide laser vascular status. rather than phenol.) A bandaid is the c. Nerve compression or neuropathy as the source of pain. only dressing used and the patient d. Subungual (beneath nail plate) bone spur. may leave in normal street shoes. e. Status of terminal diseases which will alter the surgical approach. Postoperatively, the patient simply f. Drug therapies. washes and applies a topical antibiot- * Diabetic history in the patient does not preclude surgery, but will result ic ointment or cream for 2-3 weeks, in an individualized approach. depending upon healing potential. The patient is seen twice during that Kenneth Martin Leavitt, D.P.M. period to ensure proper wound care. MEDICINE & RECONSTRUCTIVE SURGERY OF THE FOOT The procedure is effective in pre- New England Baptist Hospital, Suite 390 • 125 Parker Hill Ave. • Boston, MA 02120 venting recurrence of the offending TEL: 617-277-3800 • FAX: 617-277-3808 nail plate 98% of the time. E-MAIL: [email protected] • www.bostonfootandankle.com