Pincer Nail Deformity: Clinical Characteristics, Causes, and Managements (2024)

PMCID: PMC7180426

Chao Huang,¹ Rui Huang,² Min Yu,³ Wenlai Guo,¹ Ying Zhao,¹ Rui Li,¹ and Zhe Zhu¹

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Table 1

Conservative treatment for PND.

5.1.1. Plastic Devices

The “clyp system” is a semirigid, flexible plastic material in an elliptical shape. When subjected to pressure, they are malleable [23]. In 1993, Effendy et al. used pliant plastic braces to treat PND in the halluces of three women [22]. In 2006, Nilton et al. used the plaster mold to follow the nail widening during and after treatment to evaluate its efficacy (Figure 3) [23]. Similar to Effendy et al., after slight grinding of the nail plate with sandpaper, the nail surface was degreased with acetone to increase its adhesiveness to the plastic device. A suitable plastic device was then fixed to the nail plate with liquid cyanoacrylate glue. The larger axis of the plastic device matched the horizontal axis of the nail and was close to the free edge. During a follow-up, an alginate mold was applied to the affected hallux. Then, the mold was filled with stone plaster and removed the next day, and the caliper on the plaster mold measured the distance between the lateral nail sides. The biggest drawback for this method is the lengthened treatment period and frequent adjustments of the plastic brace [23].

5.1.2. The Shape-Memory Alloy

The shape-memory alloy has a nickel-titanium central rod and bilateral hooks that engage the nail sides (Figure 4(a)) [31]. The central bar is flexible at <25°C, making it easy to bend and apply to severely deformed nails. At >25°C, the bar's solidity increases which corrects the nails. Considering that the foot temperature is approximately 27°C to 28°C, the bar retains its firm nature [24]. In 2009, Kim and Park applied the shape-memory alloy device to treat severely incurved symptomatic toenails and achieved positive outcomes [24]. From 2010 to 2012, they used it on 14 patients with mild and severe PND and achieved satisfactory results (Figures 4(b) and 4(e)). They used a mosquito clamp to remove part of the nail embedded into the periungual skin. One side of a hook was applied to one side of the nail, while the other side of the hook was applied to the opposite side (Figures 4(c) and 4(d)). The hook was moved to the position on the nail corresponding to the starting point of the nail deformity. Finally, one/two similar devices were used depending on toenail size and PND severity. The device was removed after 10 days but can stay for 2 or 3 weeks depending on the toenail changes [14]. Thereafter, in 2014, Lee et al. used this treatment for a single case, and 4 weeks after surgery, skin necrosis developed on the back of the toe [25]. They concluded that it was caused by local infection from self-adherent bandages. Furthermore, the patient had ischemia in the submuscular course of the first dorsal metatarsal artery (FDMA) which may have contributed to necrosis. They concluded that educating the patient on skincare routine minimizes complications. Although Young Joo et al. considered the shape-memory alloy device to be inconvenient [20], the technique is used to improve the PND symptoms [24]. This technique was combined with surgical procedures on patients with hypertrophic nail fold skin [26].

5.1.3. Nail Grinding

Nail grinding is a noninvasive technique, used to treat PND since 1990 [27]. From early studies, Sano and Ichioka reported that the toenails of PND patients were approximately 0.8 mm thicker and stronger bending than those of healthy adults [32]. In 2015, they reported a case of severe PND treated by nail grinding (Figure 5), thereby reducing the automatic curvature force of the nail which balanced the mechanical force and automatic curvature [28]. This technology is evidence that mechanical stimulus-based treatments are effective. Nail deformities can be treated by balancing the automatic curvature force of the nail and the upward mechanical force from the finger/toe pad. Moreover, they suggested that further research is needed to determine the long-term results of this treatment and to establish an optimal and effective thinning method. In addition, massage, machine stimulation, and adjusting the walking posture can be effective. The nail can be softened or thinned using an external preparation, such as 40% urea paste [6] or 3% salicylic acid [29], which reduces the hardness and thickness of nails.

5.1.4. Superelastic Nickel-Titanium

From previous reports, superelastic nickel-titanium enabled bending of ingrown nails to their normal shape, providing a low-cost and effective treatment. Recently, Won et al. used dental correction principles and superelastic nickel-titanium to treat PNDs (Figure 6) [30]. This approach has three advantages. First, it can be tailored to the patient's needs. Second, it can be performed on the nail of the hallux, other toenails, and even fingernails. Third, it is noninvasive and does not limit the patient's lifestyle, enabling prolonged treatment in patients with frequently recurring PND without compliance issues.

Table 2

Surgical treatment for PND.

5.2.1. Skin Grafts and Other Tissue Grafts

In 1950, Zadik reported this technique for the treatment of ingrown and pincer nails [35]. After nail avulsion, the matrix and epithelium of the posterior wall of the nail were excised completely, and the posterior nail wall was sutured without tension to the nail bed, functioning as an advancement flap. However, two cases of flap necrosis occurred due to flap suturing under tension. In 2004, Iida and Ohsumi introduced a modified version of Zadik's method [36]. After removal of the nail matrix, including approximately 3 mm of the nail bed connected to the distal edge of the matrix, artificial skin material was used to cover the nail bed instead of an advancement flap. It was not successful because of poor wound healing. In both cases, the procedures involved destroying the nail matrix, and the final results were not cosmetically/functionally satisfying. Many patients requested preservation of the nail unit and a good cosmetic outcome. Consequently, most surgeries are aimed at preserving the nail matrix.

In 1979, Suzuki et al. first reported a PND surgical procedure with preservation of the nail matrix [37]. After removal of the nail, a median longitudinal incision was created in the nail bed to spread the tissue on the medial and lateral sides, leaving a center triangular defect. Next, a split-thickness skin graft from the forearm was sutured to this defect. During a follow up, the nail did not adhere properly and became detached. In 2000, Brown and Zook reported a long-term correction of PND by surgically implanting a dermal graft taken from the groin into the affected distal phalanx and nail bed to restore the nail bed contour [38]. However, this method was not positive due to the occurrence of full-thickness skin graft shrinkage [39].

To reduce the floating nail and shrinkage of the graft, Hatoko et al. described the use of a hard-palate mucosal graft to correct severe PND in 2003 [39]. After nail avulsion, an incision was created along the nail bed, and the nail bed tissue flap was raised at the layer above the digital bone. After flattening the digital phalanx, the surrounding tissue was bluntly dissected to spread the shrunken nail bed. When the nail bed tissue returned to its original position, the nail bed defect mainly occurred at the distal end of the bed, and the hard-palate mucosa containing the periosteum was transplanted onto that defect. During the long-term follow-up, no deformity appeared on either side of the nail bed, and epithelial formation occurred spontaneously. Therefore, hard-palate mucosal grafts are an effective option for the treatment of nail bed repair in patients with severe pincer deformities.

5.2.2. Widening of the Nail Bed

(1) Widening of the Nail Bed with Skin Flap. In 2003, Masaaki and Hiroshi described a procedure that widened the nail bed in the transverse direction with vertical incisions at the distal end [17]. Sutures were then placed in a zigzag pattern, similar to a classic W-plasty after complete release of the hyponychium and paronychium. Additionally, the skin flap was sutured in a zigzag pattern, which prevented postoperative scar contracture and trapdoor deformity. In 2007, Mutaf et al. [40] reported that removing the osteophytes helps in surgical correction of PND. After the removal of osteophytes on the dorsal surface of the distal phalanx to provide a flat surface for the nail bed, the distal part of the nail bed was enlarged in the transverse direction using a modified 5-flap Z-plasty technique. The 5-flap Z-plasty technique was invented by Mustarde [45] to correct epicanthal folds in 1959. This technique has been used extensively, and the first report of its use to treat PND was described by Mutaf et al. [40].

The above-mentioned authors reported successful results without recurrence, but Cho et al. considered the 5-flap Z-plasty procedure [40] not effective in flattening the nail bed's distal end [20]. They modified the Z-plasty design to improve its ability to flatten the nail bed's distal end and added a vertical incision to the flap to divide the nail bed into two flaps with no vertical skin incision dividing the two Z-designs at the tip of the toes. After flattening the flap (including the raised nail bed), they removed the skin around the two flaps parallel to the nail bed. The transposed flap was sutured with nylon sutures to flatten and widen the nail bed in a transverse direction. Their method utilized the successful techniques from both Masaaki and Hiroshi [17] and Mutaf et al. [40].

(2) Widening of the Nail Bed with the Combination of Splint and Nail Bed Cutting. In 2005, a splint made from an aspiration tube was used by Ozawa et al. to correct an elevated periosteal flap with intraoperative compression [21]. They fixed the splint to the proximal nail fold using Schiller's method [46] such that compression of the nail bed onto the distal phalanx and soft tissues was continuous. This technique prevented hematoma formation beneath the periosteal flap, contracture of the nail matrix and nail bed, and direct adhesion of the gauze to the nail bed. Moreover, the nail bed can be monitored for possible infection and flap necrosis using the transparent aspiration tube.

Ghaffarpour et al. proposed that PND arises from the nail bed [41]. Thus, they combined a splint made of an aspiration tube and nail bed cutting to treat PND. After removal of the nail plate, the nail bed was elevated by a “U-shaped” incision consisting of two incisions near the lateral nail and an incision through the distal part of the nail bed and pulp. Next, they created four incisions from the distal part of the lunula to the proximal end of the nail bed parallel to the normal lateral nail grooves. These four incisions ended within 2-3 mm of the distal flap, which made the nail bed wider and stretchable. The lateral parts of this stretchable nail bed were sutured to the lateral skin of the toe, and the distal part was sutured to the tip of the toe. A prefabricated transparent splint with a suction tube in the shape of a normal nail plate was then placed under the proximal nail fold on the nail bed and sutured to the outer nail wall, with the transparent aspiration tube allowing the clinicians to monitor any infection and flap necrosis [21].

5.2.3. Laser Surgery

Laser treatment is beneficial over surgical excision because it is easy to use, minimalized postoperative care, and has rapid treatment time and minimal pain. Laser treatment is cosmetically friendly, as opposed to the inevitable linear scarring from surgery. In 1988, Leshin and Whitaker described the use of a carbon dioxide (CO₂) laser for permanent nail ablation via matricectomy to treat PND with a success rate of 100% [42]. Later, Lane et al. advanced this method (Figure 7) [34]. After using a CO₂ laser to ablate the nail plate, they used it again to perform partial matricectomy to retain medial nail growth and prevent lateral nail regrowth (Figure 7(d)). Thus, removal of the lateral nail matrix is essential for treatment. The CO₂ laser is beneficial because of its inherent hemostatic properties allowing it to operate on highly vascular anatomical regions like the digits. Additionally, it has shallow penetration depth enabling the destruction of desired regions without causing extensive tissue damage to surrounding structures. This results in reduced healing time and desired cosmetic effects. Subsequently, Miller and Levitt reported successful outcomes after using a pulsed dye laser to treat PND with multiple periungual pyogenic granulomas [43].

5.2.4. Nail Plate and Bed Reconstruction

In 2018, Shin et al. used nail plate and bed reconstruction to treat PND (Figure 8) [44]. They created a 5 mm long incision in the proximal area of the nail along the nail fold to approach the nail matrix (Figures 8(a) and 8(b)). The subperiosteal dissection was performed using an elevator, and the deformed nail plate was removed to prevent injuring the nail bed. Next, using a specific instrument to bend the nail plate at the maximum curve point, the nail bed was gently detached from the distal phalangeal bone using a sharp blade (Figures 8(c) and 8(d)). The area of severe hypertrophy was carefully removed with a small rongeur, and the prominent osteophytes were carefully removed with a small burr. The nail curvature was reevaluated, and the nail bed was flattened. For severe PND cases with lateral deformities or unclear margins, 1-2 mm of the nail was removed from the lateral side of the plate. After resection, any infected lesions were removed (Figure 8(e)). To prevent recurrence, the proximal nail bed was gently ablated (Figure 8(f)). The nail fold was fixed underneath the lifted nail bed to offer support and sutured (Figures 8(g) and 8(h)). This procedure removed the bony osteophytes underneath the nail bed and prevented bony destruction, skin necrosis, and ischemia. Consequently, it is beneficial for severe bony deformities and nail deformities.

Table 3

Combination therapy for PND.

5.3.1. Nail Plate and Bed Separation Combined with Aluminum Splint Fixation

In 2003, Kim and Sim successfully treated 14 patients with severe PND using the nail plate method and bed separation technique combined with aluminum splint fixation (Figure 9) [3]. They used the focused mode of a CO₂ laser to separate the nail plate by making a longitudinal incision proximally from the lunula border to the distal edge of the nail plate. A longitudinal incision approximately 1 mm in width was created at the center of the curvature to relax the nail plate and straighten it through lifting the edges upward. Next, an aluminum splint bar was attached to the undersurface of the white free edge of the nail plate. The aluminum splint requires a free edge of approximately 2 mm. And it was made from aluminum Nigel splints and was cut to the appropriate size in accordance with the nail size, with a typical size of 3 × 10 × 1 mm. Finally, cyanoacrylate adhesive was applied between the aluminum splint bar and the nail plate, which were bound by needle holders.

5.3.2. Trichloroacetic Acid (TCA) Matricectomy and Aluminum Splint Fixation

Although Kim and Sim successfully treated PND by installing an aluminum splint below the nail plate surface [3], Chi et al. considered it difficult to insert a thick rigid aluminum strip through the gap between the nail plate and the nail bed [47]. They improved the method by fixing an aluminum splint after matricectomy to treat PND. Matricectomy utilizes phenol or sodium hydroxide, although phenol causes systemic side effects, like abdominal pain, hemoglobinuria, and purpura. However, the amount used for matricectomy (<2 ml) is not harmful. TCA, an alternative to phenol, is widely available and safer at concentrations ranging from 9090% to 100%. Both compounds cause coagulative necrosis, but they are safe when used properly [53].

TCA use in matricectomy was first reported to treat ingrown toenails. Chi et al. applied it to treat PND [47], using 100% TCA for partial bilateral nail avulsion and matricectomy, with a width of the lateral nail avulsion of approximately 3-4 mm. A septum elevator was then employed to separate the nail plate from the underlying nail bed. Next, a CO₂ laser or nail separator was used to longitudinally separate the nail plate throughout the lunula to the distal edge of the nail plate (Figure 10(a)). This longitudinal avulsion reduced the curvature of the distal nail plate. Finally, an aluminum splint bar of appropriate size was attached to the nail, and the bar was fixed to the nail plate using a self-adhesive wrap (Figure 10(b)). A satisfactory effect was obtained after a long-term follow-up. In 2015, a successful similar procedure was used by Evgenia et al. [48].

5.3.3. Surgical Matricectomy, Thioglycolic Acid (TGA), and Anticonvex Sutures

In 2017, Dikmen et al. used surgical matricectomy combined with TGA and anticonvex sutures in a study of 19 cases of PND in 14 patients [49]. They thickly applied a 5% TGA solution, embedded in gauze, directly to the affected toenail surface while the patients were in the preoperative waiting room. The nail was then covered with a minimal dressing to ensure contact between the TGA and nail surface to soften the nail plate. Thirty minutes after application, two small oblique incisions were created on the skin of the lateral aspects of the eponychial fold (Figure 11(a)). The nail plate was cut longitudinally as a nail strip using a straight pair of scissors to an approximate 3/4 mm width. Subsequently, the nail plate's ingrown segment was removed. After raising the eponychial flap outward with a hook, the nail matrix down to the periosteum was exposed and excised (Figure 11(b)). Next, after the 1-0 polypropylene suture, 2 correcting anticonvex sutures were placed in the proximal and distal parts of the softened nail plate to straighten the plate (Figures 11(c) and 11(d)). The anticonvex sutures were removed 3 months later. Using this procedure, there was a cosmetic nail shape and less pain and trauma to surrounding tissues, when compared with those achieved with flap techniques [38, 40].

5.3.4. Nail Methylation Phenolization (NMP) Combined with Surgical Treatment

The NMP has the advantages of an easy surgical procedure without specialized equipment, a minimal surgery time combined with minimal postoperative pain and bed rest, and low recurrence rates. Additionally, because phenol is antiseptic, the NMP technique can be used to treat PND complicated with infection. In early years, this method was extremely effective to treat ingrown nails. Up until 2001, Aksakal et al. used the combination of chemical matricectomy with nail bed repair to correct PND [50]. In 2001, Plusjé also used phenol combined with surgery to correct PND [51]. They applied phenol to the matrix horns before operating on the distal phalanx, contrasting Sugamata and Inuzuka's method [52].

In 2011, Sugamata and Inuzuka incised the nail plate longitudinally from the top to the root with fine-tipped scissors [52]. The excised nail's width was approximately 4-5 mm from the lateral edge of the nail plate. The incurved distal third of the nail plate was then excised transversely (Figure 12(a)). A fine cotton-tipped applicator was immersed in phenol solution at a concentration greater than 88% v/v. The posterior nail fold, nail matrix, nail bed, and lateral nail fold were cauterized completely with 5-6 cotton-tipped applicators that had been immersed in phenol for approximately 5 minutes (Figures 12(b) and 12(c)). The site of cauterization was washed with a sufficient amount of saline to inactivate the residual phenol. As a result, the nails returned to their normal lengths in 2-4 months (Figure 12(d)). All patients reported an appreciable improvement in their PND and the disappearance of pain from the halluces. Additionally, there were no serious complications, such as necrosis or phenol intoxication. The only disadvantage of this approach was the narrowness of the nail.