A 2-year-old girl with a finger injury and ingrown toenail.

Jennifer Trainor, MD, pediatric emergency room physician: The fancy name is onychocryptosis. There are several degrees of involvement ranging from minimal erythema and edema to a large, swollen toe with purulent drainage. The etiology is felt to relate to improper growth of the nail penetrating the skin. This may be due to improper nail trimming, which leaves a curved, sharp nail or to an unusual congenital shape of the nail. Tight footwear and pressure from an adjacent toe have also been implicated. Dr. Tanz: What is the treatment? Dr. Trainor: At its worst, we recommend warm soaks to decrease swelling. At times, we trim the edge of the nail or stick something underneath its lateral edge, such as dental floss, to try to encourage the nail to grow out from the skin. Some studies have shown that placing phenol on the nail bed to deaden it at its edge after trimming actually works better than trimming the nail alone in preventing recurrence. Based on the description of this child, I would have recommended warm soaks. Ingrid Polcari, MD, pediatric dermatologist: Some children may have congenital malalignment of the great toenail leading to lateral deviation of the nail, which predisposes to recurrent swelling and erythema. Dr. Tanz: What’s the role of antibiotics? Dr. Trainor: The randomized controlled trials that include antibiotics do not show any benefit. The treatment of a frank paronychia is drainage. Dr. Tanz: Three months later, at her 18-month well-child visit, the mother complained that there was still slight swelling of the left middle finger, although there were no complaints referable to the toe. It is documented that her gait was normal at that time. Three months later, at 21 months of age, the mother returned with concerns about persistent swelling and redness of the right great toe. She had been soaking the foot twice daily for 15 minutes, but the swelling was getting worse. Whenever her shoes and socks were removed, the girl says “ow”. The toe has always been red and warm to touch without drainage. The mother has not been trimming the toenail, but she reports that it does not seem to be growing. There’s no history of fever or other systemic symptoms. On physical exam, the right great toe was red, mildly swollen and very tender to palpation. The toenail was intact but shorter on its lateral edge. An X-ray was obtained. Jennifer Nicholas, MD, pediatric radiologist: The lateral X-ray nicely shows cortical erosion and irregularity of the distal phalanx of the great toe. Our biggest concern would be osteomyelitis. Malignancy is a possibility, but this would be a highly unusual location for metastatic disease. Dr. Tanz: Is osteomyelitis a frequent complication of ingrown toenails? Julie Stamos, MD, pediatric infectious disease physician: It’s a possibility, particularly if you think the infection is related to “trauma,” but I’ve never seen it. A 2-Year-Old Girl with a Finger Injury and Ingrown Toenail