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Problem Hypergranulation Tissue

Discussion in 'General Issues and Discussion Forum' started by Jenni18, Mar 10, 2011.

  1. Jenni18

    Jenni18 Member

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    I've a nervous female patient who is in her 20s. She's fit and healthy.

    She had an ingrown toenail on the lateral aspect of her hallux, it was infected with erythema to the pnf. The patient didn't want any antibiotics so instead I managed to clear the nail spike and the infection with dressings.

    However for a 6 weeks now the toe itself is ok but there is a ball of hypergranulation tissue on the distal sulci which is what she is finding painful. I have treatedby packing with kaltostat to keep the nail away and dry out the hypergran, this helped a bit but it's still there. I have tried applying 95% silver nitrate twice which again has helped but still there. All along the patient has been seperating the 2nd toe to limit any external compression.

    Due to the rate of growth on her nail it is needing cut back weekly (through self treatment) to keep the nail away. She is not wanting to have a PNA even though I have thoroughly discussed it with her. I believe that as I previously conservatively treated and sorted her other hallux that was quite badly ingrown, she is holding out that it will be fine for this one. The other one however did not have the hypergran that this one has!

    Can anyone please give me some ideas on anything else to try?

  2. Catfoot

    Catfoot Well-Known Member

    Hi Jenni 18,

    I don't understand this,

    Do you mean the patient is cutting the nail back herself?


  3. Jenni18

    Jenni18 Member

    Sorry, yes she just informed me today.

    I have been checking that the nail is still far enough back when she comes back for her appointments, approximately every week to 2 weeks. She told me today that between times she is also cutting a small bit back herself as in her opinion the nail is growing too quickly and she starts to feel pressure.

  4. W J Liggins

    W J Liggins Well-Known Member

    Hello Jenni

    As a profession we are pretty bad at saying 'if you do not wish to follow my advice then unfortunately, there is nothing else I can do for you.'. I really think that this is one of those situations. You are the professional but she is going away and treating the problem herself. She is entitled to do this, but frankly is showing you no respect at all by doing so. I cannot imagine that she would treat the advice of her her GP or dentist in the same way.

    I would very politely tell her that yes, there are things that can be done but you have refused my best advice. Goodbye.

    All the best

  5. Jenni:

    Tell the patient all she needs is a partial nail avulsion and this will eliminate the granulation tissue. If the paronychia and onychocryptosis recur on the same nail border more than two times, then a partial matrixectomy is the best way to proceed. In other words, I wouldn't be offering this patient a matrixectomy if a partial nail avulsion hasn't first been tried.

    When patients don't want to go along with my care suggestions, then I politely suggest to them that possibly they should seek a second opinion. There is no need to be upset with the patient when they don't want to do the treatment you suggest. However, you also don't want to offer treatment to patients that you don't feel comfortable with.

    Hope this helps.
  6. Lizzy1so

    Lizzy1so Active Member

    I agree, patient compliance is necessary in what is essentially a trust partnership, if your client is fiddling about with the problem herself i would suspect that she is not following your general advice. I would agree that she should seek treatment or a second opininionelsewhere because if infection follows treatment it will be you she will blame. Look after yourself first. No need to be unkind to her, just be firm.
  7. Catfoot

    Catfoot Well-Known Member

    I think there was a thread on PA a while back about protecting oneself from a non-compliant patient ?
    If admin could locate it, it might be useful to revisit it. Thanks.


  8. Jenni18

    Jenni18 Member

    Sometimes I try to help so much I don't realise until I talk about a situation or write it down that in some cases that they are not necessarily following everything I am saying, I just always presume that as they have come to me for help and I am offering advice the normal thing would be to follow it, but clearly not everyone can do that!

    Thankyou for all your advice

  9. Jenni:

    Just because a patient comes to you for help doesn't also mean that they will take your best advice to heart or allow you to perform the best treatment. Being a good podiatrist means you must also be a good psychologist.....finding the best way to approach a patient with a treatment plan so that they actually carry through with it. Patients will respect a physician more if they are firm and confident in their treatment methods rather than bending to the whims of the patient.

    If a patient says "I don't want to do that.", then I say "Well, it is your foot, not mine. If you want to continue having pain every day then keep doing what you are doing, and don't listen to my advice. I'm only trying to help you." (with a smile on my face).

    Sometimes you must be brutally honest to get through to your patients....and some patients need to be just be told that you have done all you can for them and they need to find another podiatrist that can help them....that is just the reality of being a physician.
  10. efuller

    efuller MVP

    It might be nice if you could post a picture. I've seen a couple of granulomas that I was sure that with the avulsion there was no posiblity of irritation from the nail, yet the granuloma persisted. These would bleed if you touched them. I eventually numbed the toe a tried to cut the granuloma off. Not easy because they bleed a lot and require a long time of direct pressure with lumicane to get the bleeding to stop. Once the granuloma returned after excission. I'm usually the least aggressive person out there, but I got tired of looking at these two month after month.

    I was wondering what others experience was with granulomas. Do you know if they resorb if the patient does not return?

  11. David Smith

    David Smith Well-Known Member


    From thread #4 at http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=22690

  12. Jenni18

    Jenni18 Member

    Hi Eric,

    I will try to get a photo the next time she comes into clinic.

    I am currently discussing with her about numbing the toe and excising the hypergran. Suprisingly she seems happy about me numbing the toe to take this off and investigate the sulci for any nail spikes, but is reluctant for a PNA to ensure it won't come back.

    Last edited: Mar 19, 2011
  13. Kara47

    Kara47 Active Member

    That is just plain weird! Does she understand what a PNA is ( i.e. everything you would do in this procedure with the addition of phenolisation?)

    The more people I meet the more I like my dog :)

    Cheers & good luck with this one!
  14. Catfoot

    Catfoot Well-Known Member

    jenni 18,
    It seems to me that it is the permanancy of the PNA that is scary to her. After all you would be be removing the sliver and it will be gone for ever and she will never see it again. :eek:
    I'm not taking the mickey here, and I am not a psychologist, but it seems that there is maybe some deep underlying psychological reason why she doesn't want to get rid of the problem permanently.
    If she will allow you to anaesthetise the area and remove the sliver , that's fine, let's just hope it won't come back or you'll be on the same merry-go-round again.

    It's all part of the challenge of working with people.

    Good luck.

  15. megmad

    megmad Member

    here is a new post for an old thread!

    I have a young boy with a nice ball on hypergran on the lateral distal hallux sulcus, thanks to his ingrowing nail.

    Right now my plan is to treat the infection. I have found iodine works quite nicely. it calmed down the raging swollen toe, but that now makes the hypergran look more gross (pt's little brother didnt like that... hee hee.) because the hypergran ball now "sits on top" for the surrounding tissue. anyway. i was able to remove the distal corner of the nail on his last visit and i hope that my conseravtive approach works.

    thanks for the above advice though... i will keep it in mind as i continue the journey with this pt
  16. megmad

    megmad Member

    oh i forgot.... what are your opinions on using phenol to address the hypergran?

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