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The effect of phenol on ingrown toenail excision in children
Journal of Pediatric Surgery (2005) 40, 290 – 292
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The effect of phenol on ingrown toenail excision in children Saleem Islam, Erin McKean Lin, Robert Drongowski, Daniel H. Teitelbaum, Arnold G. Coran, James D. Geiger, Ronald B. Hirschl* Section of Pediatric Surgery, CS Mott Children’s Hospital, University of Michigan Health System, Ann Arbor, MI 48109, USA Index words: Ingrown toenails; Phenol treatment
Abstract Purpose: Ingrown toenails in children are a common problem with a high recurrence rate. The objective of this retrospective data review was to compare simple excision of the nail matrix with excision plus phenol (EPP) application in the treatment of ingrown toenails. Methods: The charts of 69 children who underwent surgical treatment of one or more ingrown toenails from 1994 to 2000 were reviewed. The primary procedure was noted (excision alone [EA] vs EPP) and dates of recurrences and reoperations were recorded. Parents were then surveyed by phone regarding complications, cosmetic outcome, and overall satisfaction with the procedure. Five scale categories, ranging from bstrongly agree Q to bstrongly disagree Q, were used, with responses of bstrongly agreeQ and bagree Q considered as a good outcome. Either Student’s t test or the v 2 test ( P b .05 considered significant) was used for analysis. Results: Thirty-one patients (45%) were in the EPP group whereas the remaining 38 had EA. Mean length of follow-up was 4.3 years for the EA group and 2.1 years for the EPP group. There was no difference in age at operation or length of follow-up between the 2 groups. Boys were predominant in both groups. The survey response rate was 50/69 (73%). The recurrence rate of ingrown toenails in the EA group was 42% vs 4% in the EPP group ( P = .003). There were no significant differences in parental response with regard to operative experience ( P = .31) and the cosmetic result ( P = .13), with most of the respondents (78%) indicating a good outcome for both questions. Conclusions: The addition of phenol to the surgical excision of ingrown toenail significantly reduced the incidence of recurrence, with similar patient satisfaction and an equivalent cosmetic result. D 2005 Elsevier Inc. All rights reserved.
An ingrown toenail (unguis incarnatus) is a common condition that leads to a significant discomfort in the foot. It
Presented at the 35th Annual Meeting of the American Pediatric Surgical Association, Ponte Vedra, Florida, May 27-30, 2004. * Corresponding author. Tel.: +1 734 764 6846; fax: +1 734 936 9784. E-mail address: [email protected] (R.B. Hirschl). 0022-3468/05/4001-0052$30.00/0 D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2004.09.051
can cause the patient to abstain from many routine daily activities such as walking and sports and may result in loss of work or school days [1]. Although this condition is less common in children than in adults, it is still fairly prevalent. The cause of this disorder is not fully understood, but there may be a congenital component in some cases [2]. Some children get repeated infections of the nail folds, which may require antibiotic therapy.
The effect of phenol on ingrown toenail excision in children Table 1 Excision alone vs EPP. (Cosmesis = combined categories of bagreeQ and bstrongly agreeQ) Boys Recurrence Cosmesis Complications Burns Infection
EA (n = 38)
EPP (n = 31)
68.40% 42.10% 70.30% 15.80% 3.70% 14.80%
64.50% 4.30% 69.60% 3.20% 0.00% 8.70%
P .8 .003 .693 .119 1 .674
The treatment options are varied and range from bconservativeQ (or nonoperative) care to different types of partial excisions. This is usually based on the duration and severity of symptoms [3]. Matrixectomy by mechanical or chemical methods has been applied and widely reported [4]. The application of phenol for matrix removal has been studied mostly in the adult literature, and the results have been almost uniformly in favor of phenolization reducing recurrence and improving overall results [5-9]. However, there is a dearth of reports on the surgical treatment of ingrown toenails in children. A report from Israel detailed the use of a conservative plan in 20 patients, including education and foot care [10]. They recommended this approach as opposed to surgery. In contrast, adult studies clearly document the recurring nature of this condition if treated in this manner [4]. We have been using a phenolic matrixectomy technique for a number of years and now report our experience and compare it with simple wedge excision.
1. Materials and methods Institutional review board approval for the study was obtained from the University of Michigan. We reviewed the charts of 69 children who underwent treatment of one or more ingrown toenails from 1994 to 2000. We noted the primary procedure performed— either excision alone (EA) or excision plus phenol (EPP) —recurrences, reoperations, demographics, and complications. We then surveyed the parents by phone regarding complications, cosmetic outcome, and overall satisfaction with the procedure. A Likert scale with 5 graded categories ranging from bstrongly agree Q to bstrongly disagree Q was used, with responses of bagree Q and bstrongly agree Q being considered as a good outcome for cosmesis and satisfaction. Data were compiled on Microsoft Excel (Redmond, Wash) and analyzed using the SPSS package (Chicago, Ill). A Student’s t test or a v 2 test was used and a value of b.05 was considered significant.
291 lidocaine 1%, the edge of the nail (lateral or medial) was elevated with a hemostat and was sharply removed, by approximately 3 to 4 mm. Granulation tissue was removed using electrocautery or sharp debridement. The nail matrix was then excised in that area. Excision plus phenol was performed in a similar fashion with a local anesthetic and removal of 3 to 4 mm of the lateral or medial edge of the nail, with care taken so as not to damage the nail bed or matrix. Phenol 80% wt /wt was then applied to the area including the matrix using a cotton-tipped applicator. This process was repeated 10 times for about 30 seconds each. Pressure was applied onto the nail bed and proximally at the matrix. Care was taken to not allow the excess phenol to touch the normal surrounding skin. Immediately after phenol application, 70% ethanol was used to dilute and wash out the phenol, terminating the action. After either procedure, the care was standardized. The area was liberally coated with an antibiotic ointment and the toe was wrapped with a cotton bandage. Each patient and his or her family were instructed to keep the foot elevated as much as possible and to refrain from ambulating for 24 hours. Warm soaks in water were recommended for the following week. Pain medications, including mild narcotics, were prescribed. Patients were seen back in the clinic in 7 to 10 days and the wound was examined.
2. Results A total of 69 patients underwent treatment of an ingrown toenail from 1994 to 2000. Of these, 31 had EPP and 38 had EA. There were no differences in age ( P = .814) or sex ( P = .80) between the groups. The ages at operation ranged from 8 months to 19 years. The length of follow-up differed because of the longer duration of EA being performed (EA,
1.1. Surgical procedures Excision alone was performed in a sterile manner in either the operating room or in the clinic. After application of a toe block with a mixture of bupivacaine 0.25% and
Fig. 1
Postoperative appearance of an ingrown toenail after EPP.
292 4.3 years; EPP, 2.1 years; P = .0001). Most of the patients were boys (66%) and were equal in both groups. Our survey response rate was 73% (50/69). The number of recurrences noted was significantly different, with 42% recurring after EA whereas only 4% after EPP ( P = .002; Table 1). In terms of parental and patient satisfaction, there were no significant differences between the 2 groups, with 70% in both groups either agreeing or strongly agreeing that they had a cosmetically appealing result (Fig. 1). Complications (combined) were noted in 15.8% of the EA group, with 3.2% seen in the EPP group ( P = .119).
3. Discussion Otto Boll was the first physician to describe the use of phenol for chemical matrixectomy for treatment of an ingrown toenail in 1945 [11]. Since then, phenol has emerged as the treatment of choice for this condition in adults [4]. Multiple studies have documented a lower recurrence rate, a better cosmetic appearance, less pain, and earlier resumption of work or normal activities with this type of treatment as compared with a surgical excision of the matrix [5-9,12]. Phenol, originally called carbolic acid, was used by Lister for sterilization of the operating field until its toxic nature to the tissues was noted. It causes a chemical burn on the skin by absorbing water and coagulating proteins [4]. This property is used in the matrixectomy for treating ingrown toenails. Sodium hydroxide has been used by some with excellent results as well. This strong alkali acts by causing a liquefactive necrosis and is neutralized using acetic acid. This technique, although similar to phenol, has not been broadly adopted [4]. We adopted this approach over time as one of the authors introduced it, and it became accepted over a short period by other surgeons in the practice. The reason it was introduced was the frustratingly high recurrence rates that we were experiencing and the success in adult reports. As with all retrospective studies, there may be an element of historical bias introduced as the procedure became adopted. As previously stated in the Introduction, there are very few published reports on the treatment of ingrown toenails in children. Our results indicate that phenol is similarly effective in children as in adults. Our recurrence rate of 42% for EA is higher than reported in adults and may be a result of being less aggressive in excising the nail bed in children. Using phenol in addition to nail excision dropped the recurrence rate (and reoperation rate) to 4%. Our follow-up rate was 73%, which is reasonable for a retrospective study. However, the loss to follow-up may have resulted in an exclusion bias. Additionally, the length of follow-up is significantly different, with EA having longer follow-ups. This could potentially explain the difference in recurrence
S. Islam et al. rates. In our experience, recurrences usually occurred within 2 years, and, therefore, we would have picked up most of the recurrent ingrown toenails in the EPP group. Adult literature also strongly suggests that phenol treatment is associated with a lower recurrence rate, and we feel that this study represents that [1,4]. We did not note any differences in parental satisfaction or overall cosmetic result between the groups. None of the EPP patients had any skin burn in the surrounding area. Complications did not differ between the 2 groups either, although there was a trend to a higher number in the EA group. This mirrors the results noted in other studies. Herold et al [1] found that spikes of nails recurred in 36% of cases with excision only as compared with 7% of those with excision and phenol. They also noted significantly lower pain levels and earlier resumption of normal activities in the phenol group [1]. We could not document this in our retrospective study. Our results show a significantly lower recurrence rate of ingrown toenails by using phenol matrixectomy with an equivalent cosmetic result. We recommend that this technique be considered when treating ingrown toenails in children of all ages.
References [1] Herold N, Houshian S, Riegels-Nielsen P. A prospective comparison of wedge matrix resection with nail matrix phenolization for the treatment of ingrown toenail. J Foot Ankle Surg 2001;40:390 - 5. [2] Katz AM. Congenital ingrown toenails. J Am Acad Dermatol 1996; 34:519 - 20. [3] Mozena JD. The Mozena classification and treatment algorithm for ingrown hallux nails. J Am Podiatr Med Assoc 2002;92:131 - 5. [4] Epensen EH, Nixon BP, Armstrong DG. Chemical matricectomy for ingrown toenails: is there an evidence basis to guide therapy? J Am Podiatr Med Assoc 2002;92:287 - 95. [5] Gerritsma-Bleeker CLE, Klaase JM, Geelkerken RH, et al. Partial matrix excision or segmental phenolization for ingrowing toenails. Arch Surg 2002;137:320 - 5. [6] Bostanci S, Ekmecki P, Gurgey E. Chemical matricectomy with phenol for the treatment of ingrowing toenail: a review of the literature and follow up of 172 treated patients. Acta Derm Venereol 2001;81: 181 - 3. [7] Buckley D. Segmental phenolic ablation for ingrown toenails in general practice. Ir Med J 2000;93:242 - 4. [8] Bossers AM, Jansen IM, Eggink WF. Rational therapy for ingrown toenails. A prospective study. Acta Orthop Belg 1992;58:325 - 9. [9] Fulton GJ, O’Donohoe MK, Reynolds JV, et al. Wedge resection alone or combined with segmental phenolization for the treatment of ingrowing toenail. Br J Surg 1994;66:63 - 5. [10] Lazar L, Erez I, Katz S. A conservative treatment for ingrown toenails in children. Pediatr Surg Int 1999;15:121 - 2. [11] Dagnall JC. The history, development and current status of nail matrix phenolization. Chiropodist 1981;36:315 - 24. [12] Morkane AJ, Robertson RW, Inglis GS. Segmental phenolization of ingrowing toenails: a randomized controlled study. Br J Surg 1984;71: 526 - 7.
www.elsevier.com/locate/jpedsurg
The effect of phenol on ingrown toenail excision in children Saleem Islam, Erin McKean Lin, Robert Drongowski, Daniel H. Teitelbaum, Arnold G. Coran, James D. Geiger, Ronald B. Hirschl* Section of Pediatric Surgery, CS Mott Children’s Hospital, University of Michigan Health System, Ann Arbor, MI 48109, USA Index words: Ingrown toenails; Phenol treatment
Abstract Purpose: Ingrown toenails in children are a common problem with a high recurrence rate. The objective of this retrospective data review was to compare simple excision of the nail matrix with excision plus phenol (EPP) application in the treatment of ingrown toenails. Methods: The charts of 69 children who underwent surgical treatment of one or more ingrown toenails from 1994 to 2000 were reviewed. The primary procedure was noted (excision alone [EA] vs EPP) and dates of recurrences and reoperations were recorded. Parents were then surveyed by phone regarding complications, cosmetic outcome, and overall satisfaction with the procedure. Five scale categories, ranging from bstrongly agree Q to bstrongly disagree Q, were used, with responses of bstrongly agreeQ and bagree Q considered as a good outcome. Either Student’s t test or the v 2 test ( P b .05 considered significant) was used for analysis. Results: Thirty-one patients (45%) were in the EPP group whereas the remaining 38 had EA. Mean length of follow-up was 4.3 years for the EA group and 2.1 years for the EPP group. There was no difference in age at operation or length of follow-up between the 2 groups. Boys were predominant in both groups. The survey response rate was 50/69 (73%). The recurrence rate of ingrown toenails in the EA group was 42% vs 4% in the EPP group ( P = .003). There were no significant differences in parental response with regard to operative experience ( P = .31) and the cosmetic result ( P = .13), with most of the respondents (78%) indicating a good outcome for both questions. Conclusions: The addition of phenol to the surgical excision of ingrown toenail significantly reduced the incidence of recurrence, with similar patient satisfaction and an equivalent cosmetic result. D 2005 Elsevier Inc. All rights reserved.
An ingrown toenail (unguis incarnatus) is a common condition that leads to a significant discomfort in the foot. It
Presented at the 35th Annual Meeting of the American Pediatric Surgical Association, Ponte Vedra, Florida, May 27-30, 2004. * Corresponding author. Tel.: +1 734 764 6846; fax: +1 734 936 9784. E-mail address: [email protected] (R.B. Hirschl). 0022-3468/05/4001-0052$30.00/0 D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2004.09.051
can cause the patient to abstain from many routine daily activities such as walking and sports and may result in loss of work or school days [1]. Although this condition is less common in children than in adults, it is still fairly prevalent. The cause of this disorder is not fully understood, but there may be a congenital component in some cases [2]. Some children get repeated infections of the nail folds, which may require antibiotic therapy.
The effect of phenol on ingrown toenail excision in children Table 1 Excision alone vs EPP. (Cosmesis = combined categories of bagreeQ and bstrongly agreeQ) Boys Recurrence Cosmesis Complications Burns Infection
EA (n = 38)
EPP (n = 31)
68.40% 42.10% 70.30% 15.80% 3.70% 14.80%
64.50% 4.30% 69.60% 3.20% 0.00% 8.70%
P .8 .003 .693 .119 1 .674
The treatment options are varied and range from bconservativeQ (or nonoperative) care to different types of partial excisions. This is usually based on the duration and severity of symptoms [3]. Matrixectomy by mechanical or chemical methods has been applied and widely reported [4]. The application of phenol for matrix removal has been studied mostly in the adult literature, and the results have been almost uniformly in favor of phenolization reducing recurrence and improving overall results [5-9]. However, there is a dearth of reports on the surgical treatment of ingrown toenails in children. A report from Israel detailed the use of a conservative plan in 20 patients, including education and foot care [10]. They recommended this approach as opposed to surgery. In contrast, adult studies clearly document the recurring nature of this condition if treated in this manner [4]. We have been using a phenolic matrixectomy technique for a number of years and now report our experience and compare it with simple wedge excision.
1. Materials and methods Institutional review board approval for the study was obtained from the University of Michigan. We reviewed the charts of 69 children who underwent treatment of one or more ingrown toenails from 1994 to 2000. We noted the primary procedure performed— either excision alone (EA) or excision plus phenol (EPP) —recurrences, reoperations, demographics, and complications. We then surveyed the parents by phone regarding complications, cosmetic outcome, and overall satisfaction with the procedure. A Likert scale with 5 graded categories ranging from bstrongly agree Q to bstrongly disagree Q was used, with responses of bagree Q and bstrongly agree Q being considered as a good outcome for cosmesis and satisfaction. Data were compiled on Microsoft Excel (Redmond, Wash) and analyzed using the SPSS package (Chicago, Ill). A Student’s t test or a v 2 test was used and a value of b.05 was considered significant.
291 lidocaine 1%, the edge of the nail (lateral or medial) was elevated with a hemostat and was sharply removed, by approximately 3 to 4 mm. Granulation tissue was removed using electrocautery or sharp debridement. The nail matrix was then excised in that area. Excision plus phenol was performed in a similar fashion with a local anesthetic and removal of 3 to 4 mm of the lateral or medial edge of the nail, with care taken so as not to damage the nail bed or matrix. Phenol 80% wt /wt was then applied to the area including the matrix using a cotton-tipped applicator. This process was repeated 10 times for about 30 seconds each. Pressure was applied onto the nail bed and proximally at the matrix. Care was taken to not allow the excess phenol to touch the normal surrounding skin. Immediately after phenol application, 70% ethanol was used to dilute and wash out the phenol, terminating the action. After either procedure, the care was standardized. The area was liberally coated with an antibiotic ointment and the toe was wrapped with a cotton bandage. Each patient and his or her family were instructed to keep the foot elevated as much as possible and to refrain from ambulating for 24 hours. Warm soaks in water were recommended for the following week. Pain medications, including mild narcotics, were prescribed. Patients were seen back in the clinic in 7 to 10 days and the wound was examined.
2. Results A total of 69 patients underwent treatment of an ingrown toenail from 1994 to 2000. Of these, 31 had EPP and 38 had EA. There were no differences in age ( P = .814) or sex ( P = .80) between the groups. The ages at operation ranged from 8 months to 19 years. The length of follow-up differed because of the longer duration of EA being performed (EA,
1.1. Surgical procedures Excision alone was performed in a sterile manner in either the operating room or in the clinic. After application of a toe block with a mixture of bupivacaine 0.25% and
Fig. 1
Postoperative appearance of an ingrown toenail after EPP.
292 4.3 years; EPP, 2.1 years; P = .0001). Most of the patients were boys (66%) and were equal in both groups. Our survey response rate was 73% (50/69). The number of recurrences noted was significantly different, with 42% recurring after EA whereas only 4% after EPP ( P = .002; Table 1). In terms of parental and patient satisfaction, there were no significant differences between the 2 groups, with 70% in both groups either agreeing or strongly agreeing that they had a cosmetically appealing result (Fig. 1). Complications (combined) were noted in 15.8% of the EA group, with 3.2% seen in the EPP group ( P = .119).
3. Discussion Otto Boll was the first physician to describe the use of phenol for chemical matrixectomy for treatment of an ingrown toenail in 1945 [11]. Since then, phenol has emerged as the treatment of choice for this condition in adults [4]. Multiple studies have documented a lower recurrence rate, a better cosmetic appearance, less pain, and earlier resumption of work or normal activities with this type of treatment as compared with a surgical excision of the matrix [5-9,12]. Phenol, originally called carbolic acid, was used by Lister for sterilization of the operating field until its toxic nature to the tissues was noted. It causes a chemical burn on the skin by absorbing water and coagulating proteins [4]. This property is used in the matrixectomy for treating ingrown toenails. Sodium hydroxide has been used by some with excellent results as well. This strong alkali acts by causing a liquefactive necrosis and is neutralized using acetic acid. This technique, although similar to phenol, has not been broadly adopted [4]. We adopted this approach over time as one of the authors introduced it, and it became accepted over a short period by other surgeons in the practice. The reason it was introduced was the frustratingly high recurrence rates that we were experiencing and the success in adult reports. As with all retrospective studies, there may be an element of historical bias introduced as the procedure became adopted. As previously stated in the Introduction, there are very few published reports on the treatment of ingrown toenails in children. Our results indicate that phenol is similarly effective in children as in adults. Our recurrence rate of 42% for EA is higher than reported in adults and may be a result of being less aggressive in excising the nail bed in children. Using phenol in addition to nail excision dropped the recurrence rate (and reoperation rate) to 4%. Our follow-up rate was 73%, which is reasonable for a retrospective study. However, the loss to follow-up may have resulted in an exclusion bias. Additionally, the length of follow-up is significantly different, with EA having longer follow-ups. This could potentially explain the difference in recurrence
S. Islam et al. rates. In our experience, recurrences usually occurred within 2 years, and, therefore, we would have picked up most of the recurrent ingrown toenails in the EPP group. Adult literature also strongly suggests that phenol treatment is associated with a lower recurrence rate, and we feel that this study represents that [1,4]. We did not note any differences in parental satisfaction or overall cosmetic result between the groups. None of the EPP patients had any skin burn in the surrounding area. Complications did not differ between the 2 groups either, although there was a trend to a higher number in the EA group. This mirrors the results noted in other studies. Herold et al [1] found that spikes of nails recurred in 36% of cases with excision only as compared with 7% of those with excision and phenol. They also noted significantly lower pain levels and earlier resumption of normal activities in the phenol group [1]. We could not document this in our retrospective study. Our results show a significantly lower recurrence rate of ingrown toenails by using phenol matrixectomy with an equivalent cosmetic result. We recommend that this technique be considered when treating ingrown toenails in children of all ages.
References [1] Herold N, Houshian S, Riegels-Nielsen P. A prospective comparison of wedge matrix resection with nail matrix phenolization for the treatment of ingrown toenail. J Foot Ankle Surg 2001;40:390 - 5. [2] Katz AM. Congenital ingrown toenails. J Am Acad Dermatol 1996; 34:519 - 20. [3] Mozena JD. The Mozena classification and treatment algorithm for ingrown hallux nails. J Am Podiatr Med Assoc 2002;92:131 - 5. [4] Epensen EH, Nixon BP, Armstrong DG. Chemical matricectomy for ingrown toenails: is there an evidence basis to guide therapy? J Am Podiatr Med Assoc 2002;92:287 - 95. [5] Gerritsma-Bleeker CLE, Klaase JM, Geelkerken RH, et al. Partial matrix excision or segmental phenolization for ingrowing toenails. Arch Surg 2002;137:320 - 5. [6] Bostanci S, Ekmecki P, Gurgey E. Chemical matricectomy with phenol for the treatment of ingrowing toenail: a review of the literature and follow up of 172 treated patients. Acta Derm Venereol 2001;81: 181 - 3. [7] Buckley D. Segmental phenolic ablation for ingrown toenails in general practice. Ir Med J 2000;93:242 - 4. [8] Bossers AM, Jansen IM, Eggink WF. Rational therapy for ingrown toenails. A prospective study. Acta Orthop Belg 1992;58:325 - 9. [9] Fulton GJ, O’Donohoe MK, Reynolds JV, et al. Wedge resection alone or combined with segmental phenolization for the treatment of ingrowing toenail. Br J Surg 1994;66:63 - 5. [10] Lazar L, Erez I, Katz S. A conservative treatment for ingrown toenails in children. Pediatr Surg Int 1999;15:121 - 2. [11] Dagnall JC. The history, development and current status of nail matrix phenolization. Chiropodist 1981;36:315 - 24. [12] Morkane AJ, Robertson RW, Inglis GS. Segmental phenolization of ingrowing toenails: a randomized controlled study. Br J Surg 1984;71: 526 - 7.