Nail avulsion and chemical matricectomy

Author
Barbara M Mathes, MD, FACP, FAAD
Section Editors
Russell S Berman, MD
Robert P Dellavalle, MD, PhD, MSPH
Deputy Editor
Rosamaria Corona, MD, DSc
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2016. | This topic last updated: Jan 22, 2016.

INTRODUCTION Nail disorders, particularly ingrown, incurved, pincer, hypertrophic, infected, and painful nails, are common conditions in adults
(picture 1A-C) [1]. Although abnormalities of nails can be disfiguring, it is usually pain that brings the patient to the clinician. Most asymptomatic nail
disorders affect the toenails, but the fingernails can be affected as well. A variety of relatively simple approaches to nail problems can prevent or
alleviate symptoms, and others may correct or cure the underlying problem.

Nail anatomy and common office procedures performed on the nails are described here. The principles of nail biopsy and surgery are discussed
separately. Nail disorders and routine treatment of ingrown toenails are also reviewed separately.

(See "Nail biopsy: Indications and techniques".)

(See "Principles and overview of nail surgery".)
(See "Overview of nail disorders".)
(See "Paronychia and ingrown toenails".)

NAIL ANATOMY A basic knowledge of nail anatomy is helpful in understanding nail disorders and their surgical treatment. The nail is an
anatomic unit comprising the nail plate, nail bed, and matrix (figure 1). The nail plate is the hard, keratinized portion of nail (fingernail or toenail) that
is typically convex or flat and sits on top the distal phalanx. It is the "growing" portion of the nail unit and the cause of most symptomatic problems.
Toenails are more convex than fingernails.

The nail plate is firmly attached to the underlying nail bed and is bordered laterally by the lateral nail folds. Proximally, the nail is bordered by the
proximal nail fold and a contiguous eponychium known as a cuticle.

Proximal to the nail bed is the matrix, the portion of the unit from which most of the nail plate originates. The distal portion of the matrix can be seen
under the nail plate as the lunula or "half-moon" of the nail.

The vascular supply to the nail unit is provided by an anastomosing, arching network of arterioles extending from the digital arteries; venous
drainage is through bilateral, proximal nail fold veins. The nail unit is richly innervated by nerves coursing alongside the digital arteries [2,3].

The entire nail unit lies atop the distal phalanx; thus, bony changes including degenerative, inflammatory, and traumatic can affect the growth and
appearance of the nail. Because the nail is an epidermal appendage, conditions that affect the epidermis, including psoriasis, lichen planus,
dermatitis, and superficial fungal infections, can also affect the nail unit, thereby altering the appearance of the nail plate and bed. Nail plate growth
is faster in fingernails than toenails, averaging 0.1 mm per day or 1 cm per three months. Nail growth slows with age and with vascular insufficiency
and can be interrupted partially or completely by systemic processes including fever, surgery, significant illness, and medications.

PARING, TRIMMING, AND GRINDING Toenail paring, trimming, and grinding are commonly performed by clinicians and podiatrists on patients
with diabetes or those who have physical limitations that prevent their ability to perform routine nail care. Paring and trimming can be performed
with regular nail clippers, but heavy duty English anvil nail nippers are recommended because the slow-growing nails of older patients result in a
very thick, tough nail plate requiring the spring-handled device for satisfactory trimming (picture 2A).

Procedure Over the years, a variety of techniques including cutting the distal nail square, angling the edges, or creating a "V" in the center, have
been advocated. After trying many techniques, I prefer to customize the shape of the nail trim to its problems, most often shaping the distal edge to
the toe shape. The nails are trimmed to leave 2 to 3 mm of free nail plate, then an emery board is used to file down sharp edges that may
accidentally catch on stockings and lift the nail plate from the bed.

An ingrown portion of a nail plate deeply embedded into the lateral soft tissue can be removed by placing the tip of the nipper under the "ingrown"
edge and cutting it free. This simple procedure can temporarily provide pain relief for several weeks.

Sometimes nails are too thick and too dystrophic for nippers alone (picture 3); in this case, nail grinders are essential (picture 2B). Grinders are
drills with specially designed bits that grind and sand down the hyperkeratotic material. Grinding and sanding can eliminate a considerable amount
of thick keratin, which often substantially reduces pain by removing the hard, inflexible keratin driving into the underlying soft tissue.

Eye protection and a surgical mask or plastic face shield covering the entire face are advised when paring and grinding nails; bits of nail may fly off
when cut, and the powdery nail, often infected with fungal elements, is aerosolized.

Wound care There is no specific care advised after simple trimming, paring, or grinding, although applying a cream or lotion containing 20 to
25% topical urea daily to the nail plate helps prevent excessive thickening. If, while removing an imbedded portion of nail, the skin is broken by the
nail, a topical antibiotic covered with an adhesive bandage and washing of the site daily are recommended until there is complete healing.
NAIL AVULSION Nail avulsion is a procedure whereby all or a portion of the nail plate is removed from the nail bed. Avulsions are done for
diagnostic and therapeutic purposes. Avulsing the nail plate allows examination and visualization of lesions in the underlying nail bed and matrix.
Nail avulsions are sometimes performed when treating onychomycosis because some clinicians believe that topical application of antifungal agents
along with systemic therapy enhances therapeutic response, although good supportive data are lacking. Avulsions are most frequently done for
ingrown and incurved nails.

Sometimes nails are avulsed traumatically. When there is partial traumatic avulsion, the nail can be trimmed short and covered with an adhesive
bandage to prevent "catching" and further traumatic avulsion. An effort should be made to maintain as much of the remaining adherent nail plate as
possible so as to prevent further damage to, and keratinization of, the nail bed.

Procedure Nail avulsion is extremely painful and requires adequate anesthesia for optimal results. To begin, the patient should be in a
recumbent position. Anesthesia is provided by a digital block or wing block, supplemented with local injections. (See "Digital nerve block".)

While waiting for the anesthesia to take effect, the digit can be soaked in an antiseptic bath (povidone-iodine or chlorhexidine). Before beginning the
procedure, test for adequacy of anesthesia by inserting a needle into the digital tip and under the nail.

To begin, the operator holds the digit to keep it stable during the procedure. A narrow dental spatula, a thin small elevator (Freer septum elevator)
(picture 4), or a straight mosquito hemostat is then placed under the distal edge of the plate (picture 5). Advance the instrument longitudinally
toward the matrix in the natural cleavage plane, stopping in the area of the proximal nail groove (the tissue forming the proximal wall of the nail
matrix). Some force is initially required to advance the instrument, but then it becomes relatively easy to advance until the proximal nail groove is
reached. When performing a complete avulsion, the maneuver is repeated under a new section of nail plate, and the instrument is also moved in a
side-to-side fashion, until the entire plate is freed from underlying nail bed and adjacent nail folds. The same instrument is then placed on top of the
nail plate under the lateral and proximal nail folds to break these attachments. The free distal edge of the nail is then grasped with a hemostat and
pulled out with a side-to-side or twisting motion. Any strands of epithelium can be snipped with small scissors [ 2-4].

With partial avulsions, the instrument is advanced as before under the nail plate longitudinally until the nail groove is reached; however, the
separation of the nail plate from the nail bed is confined to the width of the plate that needs to be removed. After this is accomplished, the surface
nail attachments at the lateral fold are lysed as before. A nail splitter (picture 6) is placed under the plate, advanced the entire length of the plate,
then closed to cut the nail (picture 7). The free edge of the avulsed portion of nail is then grasped with a hemostat and pulled out.

Having removed the nail, a thin film of petrolatum (eg, Vaseline Petroleum Jelly or Aquaphor) or antimicrobial ointment (Polysporin or bacitracin) is
placed on the exposed nail bed and then is covered with a small nonadherent dressing (eg, Telfa). The entire digit is then wrapped securely, but not
too tightly, with 1- or 2-inch rolled gauze (eg, Conform). Bleeding is usually minimal if only avulsion is performed.

When operating on the toenail, advise the patient to bring an open-toed shoe or slipper to wear home after the procedure.

Wound care Simple avulsions and chemical matricectomies (see 'Chemical matricectomy' below) should be soaked in warm water 24 to 48
hours after the procedure. Before removal of the dressing, I recommend that patients soak their digit in the shower or in a bowl to avoid bleeding
and pain when the dressing is removed. A gelatinous film of epithelium is likely to appear over the exposed nail bed and can be gently removed
with dilute hydrogen peroxide on a cotton-tipped applicator. The cotton tip should be rolled over the site gently, avoiding rubbing or vigorous
attempts at tissue removal. A small amount of petrolatum or antibiotic ointment is placed on the tissue, then it is covered with an adhesive bandage
for a simple avulsion or roller gauze if a matricectomy was performed. This dressing change should be repeated daily.

CHEMICAL MATRICECTOMY Chemical matricectomy is the chemical ablation of all or part of the nail matrix. The rationale for chemical
matricectomy is to destroy the matrix to prevent the nail from growing. Typical indications are recurrent or chronically ingrown, or incurved, nails
with frequent pain or infection. Previously, surgical resections of the nail matrix also involved amputation of underlying bone and were associated
with long healing times and disfigurement. The current procedure of chemical ablation is relatively easy to perform, has minimal bleeding, allows the
patient to return to normal activities after a few days, is not significantly disfiguring, and compares favorably with surgical approaches with
recurrence rates of less than 5 percent [ 5,6]. (See "Paronychia and ingrown toenails", section on 'Recurrent ingrown toenail'.)

The procedure below describes the use of phenol in performing the chemical matricectomy. One study described more rapid healing with the use of
sodium hydroxide [7], but until additional studies are performed demonstrating efficacy, safety, and ease of use, we continue to use phenol.

Procedure Supplies needed for chemical matricectomy include a preoperative antiseptic solution, anesthesia supplies, sterile drapes, sterile
gloves, elevating instrument (dental spatula, Freer elevator (picture 4), straight mosquito forceps), nail splitter (picture 6) (for partial matricectomy),
scissors, forceps, small curette (an ear curette or other 1- to 2-mm curette), tourniquet, cotton-tipped applicators, petroleum jelly, fully saturated (88
percent) liquefied phenol, isopropyl alcohol in 20-mL syringes, petrolatum or antibiotic ointment, nonadherent gauze (Telfa), and roller gauze
(Conform). An electrocautery device is optional, as are a long-acting anesthesia (bupivacaine) and a corticosteroid (dexamethasone) for injection.

To perform the procedure, the digit must be well anesthetized with a digital block and soaked in the antiseptic solution (see "Digital nerve block").
Place the patient in a recumbent position on the operating table, and apply sterile drapes to expose the operative site. The nail plate is partially
avulsed if just a portion of the matrix is to be ablated or completely avulsed if the entire matrix is to be ablated. Any exuberant tissue should be
curetted or excised with scissors and forceps. The area of matrix to be treated is then curetted sharply. Electrocautery may be performed on this
area of matrix to control bleeding using a thin, fine tip to avoid damage to the overlying proximal nail fold tissue. A tourniquet is then placed at the
base of the digit to prevent blood from diluting the phenol. The overlying proximal nail fold, adjacent nail bed, and lateral nail folds are then coated
with petroleum jelly to prevent phenol from damaging these tissues.

Cotton-tipped applicators are stripped of all but a small wisp of cotton, or, alternatively, the bare end of the stick is covered with a small wisp of
cotton, which is then saturated with phenol solution. The cotton wisp should be held against the inside mouth of the phenol bottle to drain the
excess phenol to prevent dripping. The phenol-soaked wisp is then applied to the matrix and vigorously rubbed into the treatment area for 30
seconds. One to two subsequent phenol applications are made in a similar fashion. The tissue will denature quickly and turn white or gray. The
denaturation by phenol is self-limiting, and no irrigation is necessary. However, some surgeons irrigate the treated area with 30 to 50 mL of
isopropyl alcohol or water. The tourniquet is then removed [ 8]. The tourniquet should never be left in place for longer than 10 to 15 minutes.

After completing a chemical ablation, many clinicians inject either a long-acting anesthetic (bupivacaine) or a combination of 0.6 mL of long-acting
anesthetic and 0.4 mL of dexamethasone into the proximal nail fold (total volume of injection is approximately 0.5 mL) [ 4]. The anesthetic provides
an extended period of comfort, allowing the patient to get any needed prescription medication, get home, and elevate the treated foot or hand. I
have found that patients require less pain medication, few, if any, opioids, and are able to walk comfortably more quickly when using this technique.
Some surgeons find the addition of steroids to be helpful in preventing postoperative chemical lymphangitis, which can occur.

Petrolatum or an antibiotic ointment is placed on the nail bed, the site is covered with a nonadherent dressing (Telfa), and then the entire digit is
wrapped with 1- or 2-inch roller gauze (Conform). The wrapping should be secure but not so tight as to be uncomfortable. Dressings wrapped too
tightly may increase postoperative pain.

The patient is then advised to go home and elevate the affected foot or hand for 12 to 24 hours. Adequate elevation requires that the limb be held
above the level of the heart. Ice packs applied to the dorsal foot in the case of toenails or dorsal hand or wrist for fingernails seems to diminish pain
and slow the clearing of anesthesia. Acetaminophen, ibuprofen, codeine, or hydrocodone are appropriate analgesics when used in combination
with, but not as a substitute for, elevation. Most pain occurs in the first 24 to 48 hours, and the majority of patients can return to normal activities
while wearing an open-toed shoe after 48 hours. Persistent pain or increasing pain after two days suggests an infection or chemical cellulitis.
Infections should be cultured and treated with antistaphylococcal antibiotics; chemical cellulitis is treated with elevation, ice, and nonsteroidal anti-
inflammatory drugs.

Wound care and complications The wound care for chemical matricectomy is the same as that for simple avulsion. (See 'Nail avulsion' above.)

After a partial matricectomy, the affected nail bed begins to keratinize or harden, producing a "pseudonail," and the lateral nail fold epithelium grows
toward the remaining nail plate, eventually producing a normal-appearing nail, albeit slightly narrower. With complete matricectomy, the nail bed
keratinizes and forms a pseudonail that appears similar to a nail plate. Gauze coverings should be used postmatricectomy for one week, then
adhesive bandages should be used for an additional two to three weeks.

A chemical cellulitis can occur secondary to the denaturing of tissue by phenol. Although some degree of chemical cellulitis occurs in many cases, it
usually is not enough to warrant a visit to the clinician. Important chemical cellulitis is recognized when the swelling not only involves the digit, but
the entire foot or hand, or extends proximal to the foot or hand. Associated erythema and pain are variable. Most cases can be managed with
continued elevation of the foot or hand to above the level of the heart, alternating cold and warm compresses and nonsteroidal anti-inflammatory
drugs.

Occasionally, chemical matricectomy does not completely prevent nail plate regrowth. When the regrown nail is a small spicule, it can be grasped
with a hemostat and pulled out, a procedure that is associated with little discomfort. If a portion of the nail or the entire nail regrows, consider
repeating the procedure, performing another ablative procedure, or referral.

COMPLICATIONS Pain is the most common complication following nail surgery and is more likely to occur when infection is present before the
procedure. Permanent procedures should be avoided in the presence of infection, and infection should be treated prior to operating whenever
possible.

In my experience, most patients with persistent pain after the procedure were noncompliant with postoperative instructions regarding elevation and
ice, so I stress these aspects of wound care with my patients.

Infection is always a possibility, even when one has been meticulous with patient preparation and technique. I ask patients to contact me for the
following situations:

The pain worsens rather than improves over 24 hours

There is increasing redness of the area
A red streak develops
Pus is present
There is fever

In the first few postoperative days, bacterial infection, usually with Staphylococcus aureus, is most likely, but after one week, infections
with Candida, which tend to remain localized, are increasingly prevalent. Candidal infections usually can be treated by discontinuing the antibiotic
ointment and applying a topical antifungal agent (eg, topical clotrimazole, ketoconazole, econazole, naftifine, ciclopirox olamine). Do not use
combinations of topical antifungals and topical corticosteroids, because corticosteroids may exacerbate the fungal infection and retard healing.

CONTRAINDICATIONS Diminished vascular supply to the digit is a relative but not absolute contraindication to nail surgery. It is common for
patients with significant peripheral vascular disease, including diabetes, to have painful disorders of the nail, and surgical intervention may be
indicated. Avoiding epinephrine in the anesthetic, using digital rather than local blocks, minimizing or eliminating a tourniquet, and using palliative
rather than permanent procedures help reduce risk in these patients.

Overt bacterial infection of the operative site is a relative contraindication to chemical matricectomy, and temporizing procedures often need to be
performed. These patients should be treated with a systemic antibiotic for two to three weeks prior to surgery.
SUMMARY

Nail disorders, particularly ingrown, incurved, pincer, hypertrophic, infected, and painful nails, are common conditions in adults (picture 1A-C). A
variety of surgical techniques are used to correct or cure the underlying condition or to prevent or alleviate symptoms. These include paring,
trimming and grinding, nail avulsion, and chemical matricectomy. (See 'Introduction' above.)
Toenail paring, trimming, and grinding are commonly performed by clinicians and podiatrists on patients with diabetes or those who have
physical limitations that prevent their ability to perform routine nail care. Regular nail clippers, heavy duty nail nippers, or nail grinders may be
used (picture 2A-B). (See 'Paring, trimming, and grinding' above.)
Nail avulsion is a procedure whereby all or a portion of the nail plate is removed from the nail bed (picture 7). Nail avulsion is extremely painful
and requires adequate anesthesia by digital or wing block. Avulsion is done for diagnostic and therapeutic purposes, most frequently for ingrown
and incurved nails. (See 'Nail avulsion' above and "Digital nerve block".)
Chemical matricectomy is the chemical ablation of all or part of the nail matrix. Typical indications are recurrent or chronically ingrown or
incurved nails with frequent pain or infection. After complete or partial nail avulsion, phenol is applied to the matrix portion to be treated. (See
'Chemical matricectomy' above.)
Pain is the most common complication following nail surgery. Pain may be controlled by elevation of the affected foot or hand for 12 to 24
hours, application of ice packs to the dorsal foot or hand, and oral analgesics. (See 'Complications' above.)
Nail surgery may be contraindicated in patients with peripheral vascular disease and reduced vascular supply to the digits. W hen surgery is
necessary, avoiding epinephrine in the anesthetic, using digital rather than local blocks, minimizing or eliminating a tourniquet, and using
palliative rather than permanent procedures help reduce risk in these patients. (See 'Contraindications' above.)
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REFERENCES

Mathes BM, Alguire PC. Nail Surgery. In: Dermatologic Procedures in Atlas of Office Procedures, Alguire PC, Mathes BM (Eds), WB Saunders,
1
Philadelphia 1999. Vol 2, p.97.
2 Clark RE, Trope WD. Nail surgery. In: Cutaneous Surgery, 1st ed, Wheeland RG (Ed), WB Saunders, Philadelphia 1994. p.375.
3 Krull EA. Surgery of the nail. In: Dermatology, Moschella S, Hurley HH (Eds), WB Saunders, Philadelphia 1992. p.2403.
4 Salashe SJ. Nail unit surgery. In: Atlas of Cutaneous Surgery, Robinson JK, Arndt KA, LeBoit PE, et al (Eds), WB Saunders, Philadelphia 1996. p.189.
Bostanci S, Ekmeki P, Grgey E. Chemical matricectomy with phenol for the treatment of ingrowing toenail: a review of the literature
5
and follow-up of 172 treated patients. Acta Derm Venereol 2001; 81:181.
Andreassi A, Grimaldi L, D'Aniello C, et al. Segmental phenolization for the treatment of ingrowing toenails: a review of 6 years
6
experience. J Dermatolog Treat 2004; 15:179.
Bostanci S, Kocyigit P, Grgey E. Comparison of phenol and sodium hydroxide chemical matricectomies for the treatment of ingrowing
7
toenails. Dermatol Surg 2007; 33:680.
8 Siegle RJ, Harkness J, Swanson NA. Phenol alcohol technique for permanent matricectomy. Arch Dermatol 1984; 120:348.
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Contributor Disclosures: Barbara M Mathes, MD, FACP, FAAD Equity Ownership/Stock Options: Amgen Inc; Amgen Inc (Spouse); Express
Scripts; Express Scripts (Spouse). Russell S Berman, MD Nothing to disclose. Robert P Dellavalle, MD, PhD, MSPH Nothing to
disclose. Rosamaria Corona, MD, DSc Nothing to disclose.
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