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Are Antibiotics Necessary in the Treatment of Locally Infected Ingrown Toenails?
Alexander M. Reyzelman, DPM;
Karla A. Trombello, DPM;
Dean J. Vayser, DPM;
David G. Armstrong, DPM;
Lawrence B. Harkless, DPM
Arch Fam Med. 2000;9:930-932.
ABSTRACT
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Context A wide variety of generalists and specialists treat locally infected ingrown toenails, with perhaps the most common treatment regimen including resection of the nail border coupled with oral antibiotics.
Objective To determine whether oral antibiotic therapy is beneficial as an adjunct to the phenol chemical matrixectomy in the treatment of infected ingrown toenails.
Design We prospectively enrolled healthy patients with infected ingrown toenails. Each patient was randomly assigned to 1 of 3 groups that received either 1 week of antibiotics and a chemical matrixectomy simultaneously (group 1), antibiotics for 1 week and then a matrixectomy (group 2), or a matrixectomy alone (group 3).
Setting Institutional ambulatory outpatient clinic.
Patients Fifty-four healthy patients with infected ingrown toenails were studied. Patients with immunocompromised states, peripheral vascular disease, or cellulitis proximal to the hallux interphalangeal joint were excluded. Groups were age matched for comparison.
Results Mean healing times for groups 1, 2, and 3 were 1.9, 2.3, and 2.0 weeks, respectively. Subjects receiving antibiotics and a simultaneous chemical matrixectomy (group 1) healed significantly sooner than those receiving a 1-week course of antibiotics followed by a matrixectomy (group 2). There was not a significant difference in healing time between those that received a chemical matrixectomy alone (group 3) and those that received a matrixectomy coupled with a course of oral antibiotics (group 1).
Conclusion The use of oral antibiotics as an adjunctive therapy in treating ingrown toenails does not play a role in decreasing the healing time or postprocedure morbidity.
INTRODUCTION
INGROWN TOENAILS are one of the most common pedal foot maladies, with a prevalence of 20% of the population seeking foot care.1-3 This condition is treated by a wide variety of health care providers. Generally, patients seek treatment when the offending irritated nail border progresses to localized infection with commensurate drainage, erythema, edema, and pain. While there are a wide variety of treatments available for ingrown toenails, the chemical matrixectomy using phenol is employed most often. The use of oral antibiotics as an adjunct to treating ingrown toenails is widespread and often touted as an essential component in the treatment course.4-5 However, antibiotic necessity remains controversial. Some physicians feel that instituting oral antibiotics before performing a phenol matrixectomy or at the time of the phenol matrixectomy reduces the risk of developing further infection.6 Other investigators have indicated that once the offending nail is removed, the localized infection will resolve without the need of antimicrobial agents.7-8 The purpose of this study was to prospectively determine whether oral antibiotic therapy is beneficial in the treatment of infected ingrown toenails by chemocautery.
PATIENTS AND METHODS
During a 1-year period beginning in June 1997, we enrolled 154 patients aged 10 to 60 years. All subjects had locally infected ingrown hallux nails. This study was approved by the University of Texas Institutional Review Board, with all subjects signing informed consent prior to enrollment. Infected ingrown toenails were defined as nail borders exhibiting paronychia, granulation tissue, edema, and the presence of exudate (Figure 1). Patients with immunocompromised states (long-term steroid use, diabetes mellitus, collagen vascular disease, human immunodeficiency virus), cellulitis proximal to the hallux interphalangeal joint, or peripheral vascular disease (defined as the absence of 1 or more pedal pulses or the presence of dystrophic changes to the integument) were excluded.
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Infected, ingrown toenail.
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Each patient was randomly assigned to 1 of 3 groups: group 1 received a 1-week course of oral antibiotics (cephalexin) and a simultaneous phenol matrixectomy at the initial visit; group 2 received a 1-week course of oral antibiotics (cephalexin) at the initial visit and a phenol matrixectomy 1 week later; and group 3 received a phenol matrixectomy at the initial visit without antibiotic therapy. We chose cephalexin (500 mg, 4 x per day) for this study based on its efficacy against the coagulase-negative staphylococcal species, specifically Staphylococcus epidermidis, the most commonly cultured pathogen in infected ingrown toenails.9 In this study, 6 patients did not return for sufficient follow-up visits to be included in the final analysis of the aforementioned 154 subjects. These included none from group 1, 3 from group 2, and 3 from group 3. We randomized patients using a computerized randomization table and variable block randomization and the criteria described by Bulpitt.10
At the time of enrollment, data regarding the sex, age, and nail border involvement were recorded. Healing time was defined as the interval between the day the phenol matrixectomy was performed and the resolution of drainage and inflammatory changes surrounding the nail border. In every case, healing was identified by the principal investigator of the trial (A.M.R.).
The phenol and alcohol matrixectomy was performed using a standardized technique. The hallux was anesthetized with local infiltration of 2% plain lidocaine hydrochloride in standard ring block fashion. The nail was then swabbed with isopropyl alcohol. Exsanguination of the digit was accomplished by wrapping a half-inch Penrose drain from the apex to the base of the toe in a winding, overlapping fashion, and securing it at the base of the toe with a hemostat. The offending nail border was then freed from its soft tissue attachments with an elevator, and cut with an English anvil nail splitter. The nail plate was then removed with a hemostat. Exuberant granulation tissue present along the nail bed was excised. Next, 3 applications of 89% phenol were applied to the nail matrix with nasopharyngeal swabs for approximately 20 to 30 seconds each. Care was taken to hold the swabs at a 45° angle to the skin to avoid exposure of the nail bed to the phenol. The tourniquet was then released and the nail groove was dressed with plain 2 x 2 gauze and a self-adherent bandage. The follow-up period consisted of the patient returning 3 to 4 days later for an initial dressing change and then weekly until healing occurred. After the first dressing change, patients were instructed to cleanse the nail bed in the shower/bath per their normal routine and to apply a bandage over the toe.
To assess differences between continuous variables between the 3 treatment groups, we performed an analysis of variance. After identifying a statistical difference among groups, we used the Tukey post hoc studentized range test for simultaneous multiple comparisons to identify which groups were statistically the same and which were different. For all dichotomous variables, we used a  2 test with odds ratio and a 95% confidence interval. For all analyses, we used an  of .05.11
RESULTS
One hundred fifty-four patients were treated from June 1997 to May 1998 at our clinic. Groups 1, 2, and 3 consisted of 53, 51, and 50 patients, respectively. All groups were age-matched with an overall mean ± SD age of 20.7 ± 8.6 years (Table 1). Among the 154 ingrown toenails, the lateral border was involved in 98 patients (63.6%). The medial border was involved in 29 patients (19%) and both borders were involved in 27 patients (18%). The mean times to healing were 1.9 ± 0.7 weeks, 2.3 ± 0.8 weeks, and 2.0 ± 0.8 weeks for groups 1, 2, and 3, respectively. Group 1 healed significantly sooner than group 2 (P<.04).
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Descriptive Characteristics
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Two patients, both in group 3, developed postprocedure infections. However, there was not a significant difference in the prevalence of postprocedure infections between groups. Both patients were treated with oral antibiotics and healed uneventfully within 2 weeks. There were no postprocedure infections in groups 1 and 2.
COMMENT
The results of this study suggest that in the treatment of ingrown toenails, initial treatment with oral antibiotics may not decrease healing times. Rather, it appears as though the delay in immediate matrixectomy may have increased the duration to clinical healing. Furthermore, there was not a significant difference in healing between groups that received concomitant antibiotics and matrixectomy compared with the group that received matrixectomy alone. We are unaware of other published studies that have reported these findings.
The overall healing time for all 3 groups was approximately 2 weeks. This is significantly shorter than healing times previously reported in the literature.8, 12 We believe this is due to the technique as well as to our definition of healing. When performing the phenol matrixectomy, care was taken to only apply phenol to the matrix and not the nail bed, which can cause prolonged drainage. In addition, the definition of healing was not described in previous studies.
The locally infected ingrown toenail is a common pedal condition that is managed by a wide variety of generalists and specialists. The need to administer oral antibiotics as adjunctive therapeutic agents has remained controversial within the medical community for some time. The results of this study suggest that oral antibiotics do not play a role in decreasing healing time or mitigating postoperative morbidity when used as an adjunct to phenol matrixectomies. We believe this has significant implications for future ingrown toenail treatment protocols. In this era of cost-conscious health care administration and, perhaps more importantly, emerging antimicrobial resistance, this may be a condition for which antibiotics are not indicated.
AUTHOR INFORMATION
Accepted for publication May 24, 2000.
Corresponding author: Karla A. Trombello, DPM, Ankle and Foot Clinic, 1114 Broadway St, Longview, WA 98665.
From the Department of Orthopedics, University of Texas Health Science Center at San Antonio.
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8. Burzotta JL, Turri RM, Tsouris J. Phenol and alcohol chemical matrixectomy. Clin Podiatr Med Surg. 1989;6:453-467.
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9. Wolf EW, Hodge W, Spielfogel WD. Periungual bacterial flora in human foot. J Foot Surg. 1991;30:253-263.
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10. Bulpitt CJ. Randomized Controlled Clinical Trials. 2nd ed. The Hague, the Netherlands: Martinus Nijhoff; 1998.
11. Kirkwood BR. Essentials of Medical Statistics. Oxford, England: Blackwell; 1988.
12. Yale JF. Phenol-alcohol technique for correction of infected ingrown toenail. J Am Podiatry Assoc. 1974;64:46-53.
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