Ingrown toenails are a common nail problem that occurs when the lateral nail edge compresses the underlying soft tissue. This condition is more prevalent among adolescents and young adults, with a higher incidence among males, and it commonly affects the nails of the great toe [1-6]. Various factors can contribute to the development of ingrown toenails, such as improper nail trimming, trauma, tight footwear, infections, hyperhidrosis, obesity, and diabetes [6-10]. The typical symptoms of an ingrown toenail include pain, inflamed skin, swelling, and the formation of pus. Over time, granulation tissue can form, exacerbating the compression and leading to further swelling and discharge [11].

There are several treatment options available for ingrown toenails, ranging from conservative approaches to surgical interventions. The choice of treatment depends on the severity of the condition, the expertise of the surgeon, and the patient’s previous treatment, particularly in cases of recurrence. Conservative therapies are often recommended for mild to moderate lesions with minimal to moderate pain, little erythema, and no purulent discharge. However, moderate to severe lesions with severe, disabling pain, substantial erythema, and purulent drainage usually require surgical procedures [9].

Several surgical techniques can be used to treat ingrown toenails, such as partial or total nail avulsion, wedge resection, cryotherapy, and chemical cauterization. The ideal surgical approach should result in a high level of patient satisfaction, both functionally and aesthetically, a quick return to normal activities, and a low rate of recurrence [9,12-15]. The use of a carbon dioxide laser to treat ingrown toenails has been reported since the 1980s. Over time, several modifications have been made to reduce the recurrence rate, shorten the treatment period, relieve postoperative pain, decrease postoperative care, enhance postoperative appearance, and minimize complications [16,17].

The purpose of this study was to evaluate the efficacy of the partial matricectomy with carbon dioxide laser ablation in ingrown toenail patients.

Subjects and study design

This study is a retrospective analysis of the cases treated using partial matricectomy with carbon dioxide laser ablation in patients diagnosed with ingrown toenail from 2007 to 2022. The patient’s sex, age, clinical finding, the parameter for the performed procedure, and photographic images were collected from medical records.

Surgical technique

The surgical site was cleansed with povidone-iodine solution under digital block anesthesia with 1:100,000 epinephrine mixed 2% lidocaine. The digital tourniquet was used during surgery. The nail fold and the ingrown nail plate were then incised V-shaped using carbon dioxide laser (SP2; LUTRONIC) in superpulse mode at 3.0 watts (Fig. 1). By using freer elevator, free the nail plate from all skin attachments. The incised nail fragment was detached and removed. The exposed and separated lateral nail matrix underwent laser ablation with same settings (Fig. 2). The cause of early recurrence was insufficiently performed laser matricectomy. Therefore, it is most important to sufficiently expose the matrix after incising nail fold. We used simple interrupted suture with a 3-0 Nylon suture material to approximate the edge of the nail fold to the edge of the nail plate. And suture material was removed after 7-9 days.

Figure 1. Schematic diagram on the preoperative photographic finding. Ingrown toenail was seen on lateral nail fold. Red dotted line is incision line and yellow trapezoid indicates germinal matrix, green oval is area carbon dioxide laser cauterized.

Figure 2. Intra-operative photographic finding. The exposed and separated lateral nail matrix underwent continuous carbon dioxide laser ablation.

Evaluation of outcomes

The clinical assessment for the degree of improvement was evaluated by physicians was performed 1 month after by analyzing the clinical photographs. All patients evaluated their degree of satisfaction about current status of the ingrown toenails with 4-point scale (0, very unsatisfied; 1, unsatisfied; 2, satisfied; and 3, very satisfied) after 1 month of operation.

A total of 135 ingrown toenails in 118 patients (58 males and 60 females) were included in the study. (Table 1). The mean age of the patients was 40.86 ± 22.25 years. Twenty three patients (19.5%) had history of diabetes. And Using this procedure, 127 of 135 toenails (94.0%) were successfully treated (Fig. 3). There was no severe postoperative pain and infection. The mean time of postoperative stitch out period was 9.89 ± 3.14 days. There were 7 cases (5.2%) which took more than 2 weeks to remove the suture. Nail fold location, as recorded in the medical records, revealed 14 cases of medial nail fold and 21 cases of lateral nail fold. Recurrence was observed 8 toenails (5 males and 3 females) (Table 2). These recurred ingrown toenails were reoperated using same method and there was no more recurrence so far. Sixty-four patients responded to the satisfaction survey, and the mean satisfaction score 4 weeks after operation was 2.63 ± 0.75 (Table 3).

Table 1 . Demographic characteristics of patients

Characteristic	Result
Nails	135 (100)
Age (yr)	40.86 ± 22.25
Sex (n=118)
Female	60 (50.8)
Male	58 (49.2)
Stitch out (day)	9.89 ± 3.14
Location
Right	67 (49.6)
Left	68 (50.4)

Values are presented as number (%) or mean ± standard deviation.

Table 2 . Characteristics of patients with recurrence

Number	Sex	Location of nail fold	Reoperation
1	Male	Left lateral	56 mon later
2	Male	Right lateral	55 mon later
3	Male	Left medial	35 mon later
4	Male	Right medial	36 mon later
5	Female	Right medial	4 mon later
6	Female	Right lateral	6 mon later
7	Female	Left medial	125 mon later
8	Male	Right lateral	18 mon later

Table 3 . Patient satisfaction

Point	No. (n = 64)
0	2
1	4
2	9
3	49

Figure 3. Partial matricectomy with carbon dioxide ablation. Preoperative (A), postoperative at 1 day (B), and 16 months (C).

Insufficient data exist to establish a comprehensive understanding of the natural progression of untreated ingrown toenails, and there is no consensus regarding the most efficacious treatment modality. Nonetheless, it is common practice to address ingrown toenails promptly since they tend to persist or worsen in the absence of intervention, ultimately leading to a progressively debilitating digit and impairing an individual’s capacity to perform routine activities [18,19].

The management of ingrown toenails typically involves nonsurgical interventions; however, such approaches are often associated with a high risk of treatment failure and recurrence. As such, surgical intervention has emerged as the preferred course of action due to its superior efficacy and ability to address the underlying pathology of the condition [8,20]. There is a multitude of a surgical techniques available for the management of ingrown toenails, including total or partial nail extraction, wedge matrix excision, partial or total matrix excision, chemical matricectomy using 10% sodium hydroxide or trichloroacetic acid, nailfold excision, carbon dioxide laser matricectomy, wedge excision, phenol matricectomy, cryotherapy, and electrocautery. It is worth noting that recurrence of ingrown toenails following complete or partial nail removal, without concurrent matricectomy, may occur in up to 70% of cases [14,20-22]. Chemical matricectomy, particularly using phenol ablation, has been reported to result in a lower recurrence rate with a high rate of aesthetic outcome and low morbidity. However, there is no standardized approach for the application of chemical compounds, duration of application, or quality of matricectomy [9,21-27]. Phenol use may lead to several complications, including delayed scar healing, tissue damage, pain, allergic reaction, and exudative drainage [9,21,22,27,28]. Sodium hydroxide ablation has been reported to be effective for the treatment of ingrown toenails in patients with diabetes [29]. Trichloroacetic acid has also produced satisfactory results with a 95% success rate and good aesthetic outcomes [30]. Carbon dioxide laser is another surgical technique that has demonstrated high efficacy, with benefits including minimal tissue damage, less hemorrhage, rapid healing, and reduced postoperative pain and swelling [16,17].

The most critical aspect of ingrown toenail treatment is to selectively, completely, and reliably eliminate the affected nail matrix [17]. Selective removal is imperative to minimize damage to the normal skin and soft tissue, thereby shortening healing time and achieving a satisfactory cosmetic outcome with minimal scarring and contracture. Furthermore, complete and reliable removal of the ingrown toenail is crucial in reducing the risk of recurrence. Compared to traditional treatments, carbon dioxide laser ablation has several advantages. One of the most significant benefits of laser ablation is that it is a minimally invasive procedure that can be performed quickly, usually within 20 to 30 minutes. This means that patients can return to their normal activities soon after the procedure. In addition, laser ablation is associated with less postoperative pain and discomfort compared to traditional surgical treatments like nail extraction and matrix excision. This is because laser ablation is less invasive and causes less tissue trauma. Compared to phenol, the carbon dioxide laser achieves a higher degree of selectivity, resulting in minimal damage to surrounding tissues. As such, surgery using the carbon dioxide laser has shifted towards achieving complete and reliable removal of the nail matrix, rather than selective removal [28].

The recurrence of ingrown toenails following partial matricectomy using carbon dioxide laser ablation is a possibility due to several factors. Failure to completely remove the affected section of the nail matrix during the procedure can result in regrowth of the ingrown toenail. Furthermore, the healing process following the operation plays a crucial role in preventing the recurrence of the condition. Failure to maintain cleanliness and dryness of the wound, or an infection, can lead to abnormal nail growth. Additionally, wearing improperly fitting footwear, which exerts pressure on the toes, can also cause ingrown toenails. Inadequate postoperative care, such as not changing footwear, can contribute to the recurrence of the condition. Proper nail care, such as regular trimming and filing, is essential in preventing the development of ingrown toenails. It is crucial to develop a suitable treatment plan that accounts for all these factors to prevent the recurrence of ingrown toenails.

This study provides evidence of the efficacy of partial matricectomy using carbon dioxide laser ablation in treating ingrown toenail patients. However, the study has certain limitations, including its retrospective design, the exclusive use of partial matricectomy with carbon dioxide laser ablation, and a lack of long-term follow-up data. To address these limitations, future prospective studies will be required, which may include comparisons with other ingrown toenail treatment options.

None.

Conceptualization: DGK. Data curation: DGK. Formal analysis: DGK. Funding acquisition: ESP. Investigation: all authors. Methodology: all authors. Project administration: all authors. Software: DGK. Validation: ESP. Visualization: DGK. Writing–original draft: DGK. Writing–review & editing: all authors.

Eun Soo Park is an editorial board member of the journal, but was not involved in the review process of this manuscript. Otherwise, there is no conflict of interest to declare.

This work was supported by the Soonchunhyang University Research Fund.

Contact the corresponding author for data availability.

None.