IT IS AN AILMENT so minor that it is regarded as something of a medical joke, yet treatment for an ingrown toenail can prove absurdly complicated. For while a state-registered podiatrist can deal with this simple yet painful condition in 20 minutes using a local anaesthetic, you could — depending on your GP and local hospital — find yourself on interminable courses of antibiotics or waiting months for treatment that might involve outmoded surgical procedures carried out under general anaesthetic.
There are about 10,000 new cases of ingrown toenail in the UK each year. The condition occurs when the side of the toenail becomes embedded in the fold of skin beside the nail, causing inflammation, pain and a bacterial infection that results in further swelling and a discharge of pus. Young men between 14 and 25 seem particularly prone, probably because of squalid foot hygiene and a tendency to pick at their nails. Cutting down the side of the nail rather than straight across encourages spikes that dig into the skin, while ill-fitting shoes put pressure on the susceptible big toe.
Elderly people are at risk as their toes scroll under with age. The condition also seems to run in families.
“Ingrown toenails are one of the most poorly managed conditions you could find, whether in the NHS or in private healthcare,” says Mike O’Neill, a state-registered podiatrist and podiatric surgeon who practises in West London. Most people turn first to their GP, who usually prescribes antibiotics and warm salt baths. But even if the infection clears up, the problem tends to return three or four months later and people may stagger along for years with on-and-off doses of antibiotics, says O’Neill.
“Antibiotics are overused for this condition, and it can lead to resistance,” admits Dr Mayur Lakhani of the Royal College of General Practitioners. Lakhani, believes that the NHS fails to take the condition seriously and could provide better, quicker and more consistent care.
Twenty years ago surgical removal of the tip of the toe was still an option for a persistent ingrown toenail. Even now a doctor may remove the whole nail and its root in the nail bed so that the nail never grows back. This is known as the Zadek procedure and is usually carried out under local anaesthetic, but the toe can be painful post-operatively because of stitches. “Ask for a second opinion if anyone suggests this,” insists Liz Humble-Thomas, a state-registered podiatrist based in Oxford.
Sometimes there are good reasons for surgery — for example, with diabetes patients who are prone to infection, or those with circulation problems — but state-registered podiatrists claim that 98 per cent of ingrown toenails can be treated more conservatively, permanently and painlessly with a method called phenolisation, which was introduced to the UK in the early 1980s.
Under local anaesthetic, only the ingrown sides of the toenail are removed, and the exposed nail bed is painted with phenol, a corrosive chemical solution which destroys the tissue, preventing any future regrowth at the edges. The middle of the nail is retained, which, although narrower, leaves the toe looking more “normal”. Although critics claim that the damaged tissue is more prone to infection, podiatrists say that a swift wash-out with surgical spirit prevents this.
Some GPs do treat ingrown toenails using minor surgery, with varying success, says Lakhani. Nails can regrow, although if the skin has been cut they may be deformed: “Though where it works, it works very well,” he says.
Otherwise you will be referred to your local hospital, where much depends on the level of resources. The best have walk-in podiatry clinics for initial assessments and treatment a week or so later, but you could languish for six or eight weeks. If there is no podiatry clinic, you are in the hands of general or orthopaedic surgeons who may prefer surgical removal to phenolisation, and you could find yourself on an even longer waiting list. If you can afford it, a private podiatrist is probably the most efficient option — fees vary between £150 and £300.
One of Humble-Thomas’s patients, a dental surgeon, endured recurrent infections from an ingrown toenail for 40 years. “People laugh at the complaint, but the weight of a sheet on your toe at night can give you pain,” he says. “I suspect that many GPs have no idea that phenolisation exists, because it hasn’t been around that long. My toenail was so easily resolved that I feel rather foolish that I suffered for so long.”
Private health insurers will cover ingrown toenail treatment, but insist on a GP referral to an approved consultant, usually a surgeon. BUPA, for instance, recognises state-registered podiatrists (who have completed a BSc in podiatry and are the only members of the profession accepted by the NHS) for basic foot care for the elderly, but has approved a handful of podiatric surgeons (podiatrists who have taken postgraduate training in foot surgery under the NHS) to treat ingrown toenails. In theory an approved surgeon can refer you to a state-registered podiatrist or to a podiatric surgeon, although the medical establishment can be rather sniffy about the latter.
Many general or orthopaedic surgeons will treat ingrown toenails themselves — arguably a waste of their specialist skills and time.
Dr Natalie-Jane Macdonald, the medical director of BUPA, accepts that some patients might see a surgical consultant when a podiatrist would do, “but on balance we feel it is too complex for us to do things on a procedure-by- procedure basis. We feel that medical doctors are trained to look at the whole person, and someone may have a healthcare problem that shows in the foot but is part of a wider disease. As podiatrists become more established as a profession, we’ll keep the policy under review.”
The NHS should make more use of podiatrists’ skills, says Lakhani. “They like doing this phenol procedure and are good at it, but provision is patchy. There is an access issue about getting quick treatment, different procedures are done by different agencies, and recurrence is high. Primary care trusts need to standardise practice and agree on which cases are treated by whom: podiatrists, GPs or consultant surgeons.”
TOENAIL LINKS
www.feetforlife.org Society of Chiropodists and Podiatrists 020-7234 8620
www.bofss.org.uk British Orthopaedic Foot Surgery Society 020-7405 6507
