Involuted nail on very fleshy toes!

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I recently had a female (21 years old) who had a baby 8 months ago.
She has had persistant involuted nails since mid-pregnancy and was trying to manage them conservatively with another podiatrist.
She presented to me 2 months ago, with obvious infection of both hallucis. Her toes were VERY FLESHY along with the inflammation from infection. She was limited to wearing thongs.

I recommended she get a dose of antibiotics from the GP, then returned to me in 1 week for a PNA bilaterally of both hallucis.
This was performed well and neatly, clear of nail sulci, and dressed. Looked ok at redressing interms of healing, though there were again the overlapping flesh causing discomfort.
Post op instructions of daily salt bathing and redressing until healed.

1 month later she has returned as pain is still present. There is no nail spike, just the continued problem of there being too much meat on her toes!

Any ideas for management? I am a little lost for ideas. TNA? (seems a bit extreme.)

 

I sounds like you have not removed a large enuogh strip of nail during the PNA. The new edge of the nail has to be well clear of any granulation tissue. The larger the granuloma the wider the peice of nail that has to come out. If the new edge of the nail is still in contact with the granulation post op then the the stimulus for it to continue to grow will remain and the problem is therefore unlikely to resolve satisfactorally.

 

I have found that cutting away the granulation tissue during the procedure helps with the recovery of these cases.
Some pods cauterise the tissue also......... I although, haven't done that.

 

Thanks for your advice guys. Wasnt really what I wanted to hear, but makes sense.
Only problem is that the portion of nail removed was a fair portion and to remove more will leave her with a little slither of nail? I will put it to her and see how she feels.

Does anyone use silver nitrate for removal of granulation tissue? I havent used silver nitrate for this before, but have heard of others who do.

Thanks

 

I was working with a GP a while ago and in cases of involuted nails, he believed the nail was not the problem.

He would remove the granulation tissue/ flesh surrounding the toe like a wedge resection without touching the nail. This of course would only be done if there was no spike to remove (similar to your case)

NB. Later i did teach him how to do a PNA , he was amazed the patient could still walk after the procedure and now uses this technique.

 

There was a thread earlier in pod arena. Maybe admin can help with a link. It loked a fairly nasty technique! PNA certainly a better option in my opinion

 

I use silver nitrate fairly regularly to help the "shrinking" of granulation tissue. It usually responds very well and only one of 2 patients have noticed any post op pain but i think this is usually caused by the searching for any nail spikes.

 

Hi Guys,

Refer to a Pod Surgeon for an opinion, and possible reduction of the labial fold.

PNA's, no matter what some people think, are not a universal panacea for involuted nails.

Cheers,

 

Hey Sal,

I use Silver Nitrate aswell for cases where there is excessive hypergranulation tissue. A couple have mentioned an initial stinging but i haven't had any adverse reactions. On review it has usually dried up and flaked off or can be removed quite easily with debridement.

However, without seeing your patient i wouldn't want to say this is the best option for you.

Good luck,

Mark

 

Related to P&A's - dyou you flush your phenol with Chlorhexidine 70% or something else?

 

I heard from a pharmologically well informed source that Phenol is 'unlicensed' medication which caused some alarm to myself and others who heard this. I believe that SoCaP have had some meetings relating to Medicines Committee. Can anyone fill me in on what the situation is now?

I have routinely used Phenol for nail surgery purposes all my professional life assuming that this was an approved and licensed product for this purpose and was accepted custom and practice.

In an increasingly litigious society I would be grateful for some further advice asap although I believe SoCaP will report on this in a future journal.

 

Phenol is not licensed for podiatry use. EZ swabs are, and are obtainable from DLT. Regarding excessive hypergranulation electrofulguration/desiccation would be the answer following resection of the offending nail.

 

Hello Marion and JMD
From what I understand, Phenol is not officiay licensed for use in podiatry.. But SoCaP have given the ok for its use as it has historically been used and is successful in the treatment of IGTN's. Of course it is not administered by pregnant / breast feeding podiatrists, or used on patients likewise. Usual precautions have to be taken ie ventilation of surgery, protection of the surrounding skin and the wound washed with IMS. The use of EZ swabs was discussed with the pharmacist who supplies us with phenol. He told us that the applicator is licensed but not the phenol. (My info on the license may be out of date, so I would be interested if anyone has any up to date details) We did try them but found that they were expensive.We were told by the rep that each swab should be used for 1 minute. A bilateral PNA on both first toes meant that you used 6 swabs!

 

AGNO3 will work on frank hypergranulation tissue. However, the OP refers to 'very fleshy' or 'meaty' toes overlying the nail.

The appropriate treatment in such a case is a Winograd excision (or similar treatment) to remove the excessive tissue. As David Holland correctly points out, it's a matter of 'horses for courses'; like so many conditions, there is no universal panacea.

Hope that this is helpful.

Bill Liggins

 

I have also used silver nitrate on granulation tissue with good results.
I am just wondering if some of this pain the client is experiencing isnt from the this granulation tissue and not the nail at all.

 

"I recently had a female (21 years old) who had a baby 8 months ago.
She has had persistant involuted nails since mid-pregnancy and was trying to manage them conservatively with another podiatrist.
She presented to me 2 months ago, with obvious infection of both hallucis. Her toes were VERY FLESHY along with the inflammation from infection. She was limited to wearing thongs."

Just so that we're all clear on this - is the problem hypergranulation tissue, or healthy labial tissue?

I think we can take it for granted that
a)phenol works in whichever form you wish to purchase it
and
b) most GPs know very little about toe-nails - in sickness or in health.