CALLOUSED NAIL GROOVE
The formation of hardened, or calloused skin in the nail groove is,
unhappily, a very common occurrence. In our present day of high-heeled
and pointed shoes the nail grooves of all the nails, but particularly
those of the great toe, are subject to a great amount of pressure and
friction. This irritation develops conditions in these structures,
ranging from a transient inflammation to the formation of distinct
helomata, or the general callousing of the whole surface of the groove,
both under and beside the nail.
In many cases where an heloma has developed in the inner lateral nail
groove of the great toe, the condition is judged and treated as an
ingrown nail.
Why this error in diagnosis should occur is hard to reason out, for,
while the subjective symptoms of the two conditions may be and usually
are similar, the objective symptoms are so entirely different that the
only accountable reason for a mistaken diagnosis is carelessness or
ignorance on the part of the practitioner. The true ingrown nail is not
a particularly common occurrence and, as has been previously explained,
a nail to be classified as ingrowing, must present an edge that has
invaded and is imbedded in the softer tissues of the adjacent nail
fold. In calloused nail groove, nothing of this nature has occurred and
it is the maltreatment of cases of this kind that usually leads to true
cases of ingrown nail.
=Definition.= A calloused nail groove is a condition in which a
localized heloma (sometimes several disseminated helomata), or a
general calloused condition has developed in a lateral nail groove.
=Symptoms.= _Subjective symptoms_: excruciating pain on the slightest
pressure, heat, and throbbing in severe and neglected cases.
_Objective symptoms_: swelling, usually localized in the nail fold
involved; redness and general inflammatory condition; upon close
examination the heloma or the callous is easily demonstrated in the
fold by reason of its unyielding qualities.
=Etiology.= This condition may be caused by irritation of the tender
tissues of the nail fold brought on by persons who persist and delight
in “digging” about the edges of the nail with some instrument. In most
instances, however, a short or narrow shoe or stocking will cause
sufficient pressure of the edge of the nail upon the tissues of the
groove to cause nature to provide a protection which tends to prevent
the nail from piercing these softer tissues; the protection appears in
the form of callous. This callous will appear as a hard development
throughout the whole nail groove, and we find those tissues to be
unyielding and to have lost nearly if not all of the pinkish tint
which the great amount of vascularity underneath normally gives to the
tissues about the nail. The color is yellowish or sometimes greyish
white. Where a distinct heloma is present, it may be found covered by a
thin sheet of callous which covers some part of the groove, or it may
be distinctly independent and isolated from any such development. When
this latter condition is met, the heloma will usually be found to be
circumscribed, its edges regular and its shape circular. These latter
instances are not so common as the general callousing of the entire
groove. Where the helomata are found disseminated, they will usually
occur on the inside of the flap next the nail, although in some cases
they will be found under the edge of the nail itself. In these first
mentioned instances the pain will be greatest upon lateral pressure and
in the latter upon dorsal or plantar pressure.
=Treatment.= Various methods of treatment are employed for the
alleviation or cure of this painful ailment. They may be divided, for
discussion, into two general classes: surgical and medical.
=Surgical Treatment.= This method consists in removing the callous or
the heloma by means of a fine-pointed scalpel or a small curette. The
nail groove is first well softened by the application of small pledgets
of cotton saturated with warm water, or by the use of some epidermic
solvent such as liquor potassae, after which the parts are dried and
the operation is begun. With a sterile nail chisel sufficient of the
edge of the nail is cut away so that the heloma or the callous is
exposed. This not only gives the patient instant relief but also allows
room for the operation and the subsequent dressing.
With a pointed scalpel or bistoury, the growths are removed, much in
the same manner as helomata in any location might be treated. If the
calloused condition be general throughout the groove, a small curette
is used and the callous is loosened from the anterior end of the fold
and stripped backward toward the root of the nail.
The subsequent treatment consists in applying an ointment, such as
ammoniated mercury (5%), and packing the nail groove with sterile
gauze. Should the operator prefer a liquid, the gauze packing may be
saturated with bichloride of mercury, ¹⁄₅₀₀₀, or boric acid, saturated
solution; but it will be generally found that the ointment is more
effective in reducing the inflammatory symptoms present and also any
irritation which may have been caused during the operation.
Whilst this operation is being constantly performed and seems to be
generally in vogue, much more satisfactory results are obtainable from
local medical applications.
In the first place, in using a scalpel or curette in the nail fold,
the operator must be very skillful in order not to cause a hemorrhage
and subsequently a tender digit. In many instances, no matter how
skillful the operator, or how much care be exercised in the operation,
it will be found a practical impossibility to strip the callous from
a nail groove without capillary rupture. This latter, of course, is
undesirable and usually, no matter how the lesion is dressed, the
groove remains tender for days.
In some cases the small helomata found in the nail fold should at
once be at least partly removed, to give the patient relief. This may
be done with a fine-pointed scalpel and local treatment may then be
applied.
=Medical Treatment.= There are two methods of medical treatment
employed. One finds its efficacy in the use of salicylic acid as an
epidermic disintegrant, and the other in the application of liquor
potassae (potass. hydrox. 5%) as a cuticle solvent.
_Salicylic Acid._ After a sufficient portion of the nail has been
removed to give relief to the patient, the nail fold is thoroughly
cleansed and dried and the following ointment applied in the groove:
Acidi salicylici 8.00
Camphorae
Chloral aa 0.30
Ceratum 30.00
M. ft. unguentum
After a week or ten days has elapsed, the whole calloused area will be
found to be entirely disintegrated and may be easily removed with a
fine-pointed excavator. The groove is then packed with either gauze or
cotton, and an appropriate ointment or solution is applied to alleviate
the inflammatory condition.
The treatment with salicylic acid is easily combined with the surgical
treatment, if it be found necessary to remove a portion of the corneous
formation in order to afford relief to the patient.
In some cases it will be found efficacious, after the callous has been
removed by means of the salicylic ointment, to apply silver nitrate
(50%) to the groove. This will reduce the inflammatory conditions and
at the same time act as an astringent to the underlying capillaries and
as a sedative to the inflamed tissues. The alternate weekly use of the
ointment and the silver salt is advocated, and gratifying results are
usually obtained from this treatment in cases where it can be used.
_Liquor Potassae._ Potassium hydroxide solution is most generally used
in cases where the callous is general in the nail fold rather than
where there is simply a localized heloma.
An applicator is saturated in the solution and rubbed over the
calloused area until the mass is softened, when it may be easily
removed. While this mode of treatment is a popular one it has been
the experience of many practitioners that the liquor potassae
merely softens the calloused condition, failing to disintegrate it
entirely, and allows the parts to harden, directly the application is
discontinued. Joseph Renk, a well known New York practitioner, reports
the best of results from this treatment, when carefully used.
No doubt there are good features in both treatments and a wise
practitioner, utilizing both, will adopt that from which he obtains the
best results.
In no instance should the nail fold be packed tightly in these cases.
The operator should remember that if he removes a sliver of nail
one-sixteenth of an inch in width and then packs the resultant space
with a pledget of cotton, gauze or lamb’s wool one-eighth of an inch
in thickness, he will cause more pressure to be brought to bear on the
parts than there was originally present; this is, of course, to be
avoided under all circumstances.
On the other hand it must be remembered that sufficient packing should
be used to retain the normal line of the nail fold and to keep these
softer tissues in the proper place. Under no circumstances should they
be allowed to crowd up and over the nail, for if this does take place
we are merely setting the stage for a possible ingrown nail. Jack
Grossman, M.Cp., makes this a strong point in his talks to the students
of The First Institute of Podiatry.