Cochrane - Phenol

Surgical treatments for ingrowing toenails (Review)
Rounding C, Bloomfield S
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2008, Issue 4
http://www.thecochranelibrary.com
Surgical treatments for ingrowing toenails (Review)

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Analysis 1.1. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 1 Symptomatic
recurrence at 6 months or more. . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Analysis 1.2. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 2 Asymptomatic
recurrence at least 6 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Analysis 1.3. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 3 Recurrence at 6
months or more. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Analysis 1.8. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 8 Post operative
infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Analysis 2.1. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 1 Symptomatic recurrence at 6 months
or more. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Analysis 2.3. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 3 Recurrence at 6 months or more. 25
Analysis 2.7. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 7 Patient dissatisfied with procedure. 26
Analysis 2.8. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 8 Post operative infection. . . . 27
Analysis 3.3. Comparison 3 PHENOL AND AVULSION vs PHENOL AND SURGERY, Outcome 3 Recurrence at 6
months or more. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Analysis 4.1. Comparison 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION, Outcome 1 Symptomatic
recurrence at 6 months or more. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Analysis 4.3. Comparison 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION, Outcome 3 Recurrence at
6 months or more. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Analysis 4.7. Comparison 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION, Outcome 7 Patient
dissatisfied with procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Analysis 4.8. Comparison 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION, Outcome 8 Post operative
infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Surgical treatments for ingrowing toenails (Review) i

[Intervention Review]
Surgical treatments for ingrowing toenails
Catherine Rounding1 , Sally Bloomfield2

1
Institute of Health Sciences, National Perinatal Epidemiological Unit, Oxford, UK. 2 Gabatta clinic, Gabalfa, Cardiff, UK
Contact address: Catherine Rounding, Institute of Health Sciences, National Perinatal Epidemiological Unit, Old Road, Headington,
Oxford, OX3 7LG, UK. cath.rounding@perinat.ox.ac.uk.
Editorial group: Cochrane Skin Group.

Publication status and date: Edited (no change to conclusions), published in Issue 4, 2008.
Review content assessed as up-to-date: 27 October 2002.
Citation: Rounding C, Bloomfield S. Surgical treatments for ingrowing toenails. Cochrane Database of Systematic Reviews 2003, Issue
1. Art. No.: CD001541. DOI: 10.1002/14651858.CD001541.pub2.
ABSTRACT
Background
Ingrowing toenails are a common condition which, when recurrent and painful, are often treated surgically.
Objectives
To evaluate the effectiveness of methods of the surgical treatment of ingrowing toenails.
Search strategy
Electronic database searching (CENTRAL, MEDLINE, EMBASE, CINAHL) followed by investigation of reference lists of the papers
identified from the initial search.
Selection criteria
Any randomised (or quasi-randomised) controlled trial which compares one form of surgical removal of all or part of a toenail due to
its impact on the soft tissues to another or others. Studies must have a minimum follow period of six months and aim to permanently
remove the troublesome portion of the nail.
Data collection and analysis
Data extraction was carried out independently by the two authors using a pre-derived data extraction form and entered into RevMan.
Categorical outcomes were analysed as odds ratios with 95% confidence intervals.
Main results
Avulsion with phenol versus surgical excision
Phenolisation combined with simple avulsion of a nail is more effective than the use of more invasive excisional surgical procedures to
prevent symptomatic recurrence at six months or more (OR 0.44; 95% CI 0.24 to 0.80).
Avulsion with phenol versus avulsion without phenol
The addition of phenol, when performing a total or partial nail avulsion dramatically reduces the rate of symptomatic recurrence, (OR
0.07; 95% CI 0.04 to 0.12). This is offset by a significant increase in the rate of post-operative infection when phenol is used (OR
5.69; 95% CI 1.93 to 16.77).
Surgical treatments for ingrowing toenails (Review) 1
Authors’ conclusions
The evidence suggests that simple nail avulsion combined with the use of phenol, compared to surgical excisional techniques without
the use of phenol, is more effective at preventing symptomatic recurrence of ingrowing toenails.
The addition of phenol when simple nail avulsion is performed dramatically decreases symptomatic recurrence, but at the cost of
increased post-operative infection.
PLAIN LANGUAGE SUMMARY
Surgical interventions for ingrowing toenails
Ingrown toenails occur when the skin at the side of a nail is punctured or traumatised by the growing nail. This causes inflammation
and sometimes infection. After removing part or all of the nail causing the problem, options to prevent recurrence include removing
the nailbed and/or applying phenol (a caustic liquid). The review of trials found that removing the ingrown nail and using phenol
on the nailbed was more effective at preventing recurrence than nailbed removal. However, people whose nailbeds were treated with
phenol were more likely to have infections than those whose nailbeds were untreated after the surgery.
BACKGROUND nails can thicken, so making them more difficult to cut and more
inclined to put pressure on the skin at the sides of the nail.
Description of the condition Description of the intervention

Onychocryptosis or ingrowing toenails is a common condition For most cases, conservative treatment in the form of basic foot care
with an estimated 10,000 new cases presenting in the UK each and footwear advice is probably adequate to relieve the symptoms.
year (Sykes 1986) usually affects the big toe but may also affect the When the problem is recurrent, health professionals often view
lesser toes (DeLauro 1995). The condition occurs when the nail surgery as the best treatment option to permanently remove either
plate punctures or traumatises the skin at the side of the nail, giving the whole nail or just the troublesome portion of the nail.
rise to pain, inflammation and sometimes infection. When the Surgical procedures are carried out routinely under a local anaes-
nail punctures the skin, attempts at healing lead to the formation thetic by general practitioners (GPs), podiatric surgeons, podia-
of highly vascular tissue called granulation tissue. This continues trists, general surgeons and orthopaedic surgeons. Podiatrists al-
to be produced until the splinter of nail is removed. most always carry out nail avulsion with phenolisation. The phe-
The nail may push laterally or distally against the flesh of the toe nol is applied to nail matrix after the troublesome nail section
for a variety of reasons but if the footwear is a poor fit it will always has been removed. Its caustic action destroys the nail matrix and
worsen the problem. People born with a nail plate which is very should prevent regrowth. Other professions can choose the more
curved from side to side are predisposed to ingrowing toenails. invasive methods of surgical excision of the nail matrix. Use of cry-
Ingrowing toenails are most frequently seen in adolescents and oprobe and use of negative galvanic current are less usual methods
young adults but it is a common problem in all age groups. In of nail bed ablation which have been used by practitioners
adolescence the feet perspire more causing the skin and nails to
become soft. The softness of the nails often means they split eas-
ily, so producing nail spicules which can easily pierce the flesh. In
older people, the problem is usually chronic and more a problem
Why it is important to do this review
of reduced ability to care for the nails because of reduced mobility Despite various trials, there is disagreement on which procedures
or impaired vision. As part of the natural ageing process the toe- produce the most consistent results. Variation in practice (Sykes
1986) and patient satisfaction (Laxton 1995) is still wide. A survey Types of interventions
of current practice of GPs in Oxfordshire, UK (Milwain 1998, Any procedure which aims to permanently remove all or part of a
unpublished) further demonstrates this variation in practice. In nail due to its impact on the soft tissues.
this survey, most GPs undertook the surgery themselves rather than
referring to hospital or podiatry departments. The results showed
that three procedures were used almost equally commonly. These Types of outcome measures
were wedge excision of the nail matrix combined with the chemical
ablation; wedge excision alone and simple avulsion with chemical
ablation. Only one GP mentioned using the less conventional Primary outcomes
technique of cryotherapy. In an audit by Laxton, podiatrists using
phenolisation achieved the lowest rates of regrowth (13%) and • Regrowth/relief of symptoms
the highest rates of patient satisfaction when compared to GPs,
general and orthopaedic surgeons. The rates of regrowth for GPs
Secondary outcomes
were 34% and 50% for general surgeons. Not surprisingly, levels
of patient satisfaction reflected this. • Healing time
This systematic review will draw together evidence on the different • Infection
options for surgical treatment of ingrowing toenails with the aim • Post-operative pain - both duration and intensity of pain
of enabling practitioners and consumers to make informed choices • Patient satisfaction
on the most effective way to cure this very common problem.
Search methods for identification of studies
OBJECTIVES
To evaluate the effectiveness of methods of the surgical treatment Electronic searches
of ingrowing toenails. The object of performing surgery on an in- Section 5 of the Cochrane Collaboration Handbook (1997) was
growing toenail is to prevent its recurrence and so cure the prob- used as a guide to identify the optimum number of relevant RCTs.
lem. Therefore the primary outcome measure is the degree of re- An electronic search of CENTRAL was undertaken, followed by
growth. searches of other databases (MEDLINE post 1993, EMBASE,
CINAHL) which have not yet had their RCTs incorporated into
CENTRAL
METHODS Electronic searching of Cochrane Skin Group’s specialist register
of trials (please see Appendix 1 for the search terms used).
Criteria for considering studies for this review Searching other resources
Schools of Podiatry were contacted to request dissertation bibli-
ographies and information on unpublished studies.
Types of studies
Reference lists of all papers identified by electronic searching were
Any randomised (or quasi-randomised) clinical trial which com- searched.
pares one form of surgery to another or other treatments. The Contact with manufacturers of cryotherapy, radiowave and elec-
studies must have a follow-up period of at least six months so that trosurgical equipment to identify published or unpublished stud-
it is possible to evaluate whether the problem has been cured. ies.
Types of participants
Data collection and analysis
Males and females of any age who require surgical removal of all
or part of a toenail due to its impact on the soft tissues. Those
who have had unsuccessful surgical procedures previously were
included. Those with risk factors such as diabetes and peripheral Selection of studies
vascular disease were to be included, making the assumption that
a patient would only be considered if they have been assessed and
Selecting trials for inclusion:
found to be a suitable candidate for surgery.

Two independent authors selected all randomised controlled trials Results of the search
which met the inclusion criteria. (Disagreements were resolved Twenty-one studies were identified for possible inclusion in the re-
through discussion). Quasi-randomised trials, where the allocation view. From these, nine fitted the inclusion criteria (Anderson 1990;
to procedures was not adequately concealed (eg allocation by date Andrew 1979; Greig 1991a; Issa 1988; Leahy 1990; Morkane
of birth) were also be included but a sensitivity analysis was carried 1984; Tait 1987; van der Ham 1990; Varma 1983). Two stud-
out to see if excluding the one trial using this type of allocation ies are awaiting further information/data from the authors (Sykes
would significantly alter the results. 1988b; Sykes 1988c) and one awaits clarification from the authors
(Zaborszky 1997). Sykes 1988b appears to be a randomised trial
but does not publish data. Sykes 1988c compares different pro-
Data extraction and management
fessionals (surgeons and chiropodists) performing phenolic abla-
Data extraction was carried out independently by the two authors tion and therefore does not fit the inclusion criteria. However, the
using a pre-derived data extraction form. Data was entered into authors initially set out to compare phenolisation against surgi-
RevMan. cal avulsion, but poor results led to the surgical avulsion arm of
the trial being discontinued. If additional data was available from
Assessment of risk of bias in included studies the authors, this could be an important study. The study awaiting
clarification from authors (Zaborszky 1997) is a Hungarian study
in which the paper did not describe the methodology adequately
Assessment of methodological quality enough to be able to make a judgement as to whether the study
was prospective or whether allocation/concealment was adequate.
Two authors critically appraised the papers independently to a
The study could not be definitely excluded until this can be clari-
pre-defined standard. There was little disagreement, and this was
fied.
resolved by discussion. There as no need to pass to a third author, as
originally planned, if the disagreement had persisted. The studies
were assessed on quality of allocation concealment, intention-to-
Included studies
treat analysis, baseline comparability and completeness of follow-
up. The nine included studies compared a variety of procedures in
different combinations. All included the use of phenol and avul-
sion of all or part of the nail in their trial but some combined
Assessment of heterogeneity phenol with an excisional procedure (involving surgical removal of
Heterogeneity between comparable trials was assessed using clini- the nail matrix) and either compared it against phenolisation with
cal judgement and tested using the chi-square test available in the avulsion alone or excisional surgery alone. Some trialists were spe-
RevMan software. If significant heterogeneity was found statisti- cific in their surgical methods, naming the actual procedure used
cally, sensitivity analysis with respect to patient characteristics, for eg Winograd, while others were less so, using the broader term of
example, those with diabetes, was to be performed to identify the ’wedge excision’. One study (Greig 1991a) compared the use of
source. If the heterogeneity could still not be explained then the partial nail avulsion and phenolisation with simple partial or total
random effects model will be used. Where studies are found to be nail avulsion alone. It was debatable whether this study fitted the
suitably homogenous, meta-analysis was performed. inclusion criteria but as its aim was to permanently remove the
problem it was decided that the study should be included.
All the included studies were quite open in their inclusion criteria.
Data synthesis None excluded participants by their age or medical history. Three
The categorical outcomes were analysed as odds ratios with 95% studies (Greig 1991a; Morkane 1984; van der Ham 1990) ex-
confidence intervals, with continuous outcomes such as pain or cluded participants who had had previous toenail surgery and one
healing time as effect sizes. study (Anderson 1990) only included participants who had previ-
ously had two or more surgical procedures on their toenail. partici-
pants were generally drawn from referrals from general practition-
ers, accident and emergency departments and referrals to general
surgeons from unspecified sources. All the trials were undertaken
RESULTS
by general surgeons, normally on an outpatient basis.
All trials measured recurrence as an outcome although two did
not specify whether or not the recurrence was symptomatic (Issa
Description of studies 1988; Morkane 1984). Post-operative infection was recorded in
See: Characteristics of included studies; Characteristics of excluded four trials (Anderson 1990; Greig 1991a; Leahy 1990; Tait 1987).
studies; Characteristics of ongoing studies. Pain intensity and/or duration was reported in five trials (Issa 1988;

Leahy 1990; Morkane 1984; Tait 1987; van der Ham 1990 but The addition of phenol, when performing a total or partial nail
usable data were not supplied. Similarly healing time was reported avulsion dramatically reduces the rate of symptomatic recurrence,
in four trials (Andrew 1979; Tait 1987; van der Ham 1990; Varma with OR = 0.07 (95% CI 0.04 to 0.12; Analysis 4.1). This is offset
1983) but not with usable data. by a significant increase in the rate of post-operative infection
when phenol is used (OR = 5.69; 95% CI 1.93 to 16.77). Fewer
participants who had had phenolisation were dissatisfied, despite
Excluded studies the increased incidence of post-operative infection (OR = 0.19;
Nine studies were excluded from the review. Four studies had a 95% CI 0.11 to 0.34; Analysis 4.7). It is important to bear in
follow-up period of less than six months (Beaton 1990; Burssens mind that these results are drawn from only one study of 168
1987; Goslin 1992; Holt 1987), two did not compare interven- participants (Greig 1991a).
tions (Sykes 1988a; Greig 1991b) and one was retrospective (Ful-
ton 1994). One study (Gem 1990) had such a large loss to follow-
up (>30%) that it was decided that it should be excluded. The final Avulsion with phenol versus surgical excision
excluded study (Wallace 1979b) did not fit the inclusion criteria in Phenolisation combined with simple avulsion of a nail is more ef-
the sense that one of the interventions did not aim to permanently fective than the use of more invasive excisional surgical procedures
remove all or part of a nail. to prevent symptomatic recurrence at six months or more (OR =
0.44; 0.24 to 0.80; Analysis 1.1). There was no significant hetero-
geneity between studies with a p > 0.1. Although results from five
trials were used (Andrew 1979; Leahy 1990; Tait 1987; van der
Risk of bias in included studies
Ham 1990; Varma 1983) one trial (van der Ham 1990) had more
than twice the number of participants as any other trial and had a
large influence on the results. When sensitivity analysis was carried
Allocation
out excluding the trials considered to have inadequate allocation/
All the included trials were described as randomised although three concealment (Andrew 1979; Tait 1987) the OR was 0.47 (0.23
did not state the method used. Of the remaining trials, three allo- to 0.95); the results were still statistically significant.
cated by sealed envelopes (Leahy 1990; van der Ham 1990; Varma There were too few data in the comparisons between phenol com-
1983), one by random numbers (Issa 1988), one by hospital num- bined with surgical excision and phenol (used alone), and phe-
ber (Andrew 1979) and one by date of birth (Tait 1987). nol combined with surgical excision and surgical excision alone to
draw any clear conclusions.
Blinding
Due to the nature of the interventions it was not possible to blind
the operator to the procedure. Blinding the patient to the pro- DISCUSSION
cedure would be difficult but possible, but no study mentioned
any attempt to do this. Two trials (Anderson 1990;Leahy 1990)
used an independent observer to follow-up the procedures at six
Summary of main results
months or more. The other trials did not state who they used to
follow-up the procedures. All the studies included in the review were identified on CEN-
TRAL. The Hungarian study (Zaborszky 1997), for which more
information is required before it can be assessed, was found on
Incomplete outcome data MEDLINE. Although schools of Podiatry were contacted, and
Follow-up was very complete with all studies reporting the number their response was good, no studies meeting the inclusion criteria
of participants lost to follow-up. Seven of the nine included studies were identified. Equally, the manufacturers of cryotherapy, radio-
had a loss to follow up of 3% or less with the remaining two therapy and electrosurgical equipment responded well but no suit-
having loss to follow-up of 13% (Tait 1987) and 6% (Varma 1983) able studies were identified from this avenue. Two ongoing studies
respectively. have been identified (Crawford 2001; Thomson 2001) from the
National Research Register for possible inclusion in the review.
While all included trials measured the primary outcome of the
review, ie recurrence, other outcomes could not be quantified, as
Effects of interventions
insufficient data were available. No conclusions could be drawn
on the differences in healing times, degree of pain and frequency
of infection between different procedures, except in Greig 1991a
Avulsion with phenol versus avulsion without phenol
where infection rates were significantly lower in the group which

had simple avulsion without the addition of phenol. This outcome Implications for practice
was to be expected as although phenol is antiseptic it is also highly
From the results of one study, the addition of phenol when sim-
caustic, causing more tissue damage and so more opportunity for
ple nail avulsion is performed decreases symptomatic recurrence,
infection. It was interesting to note, however, that in the discussion
but at the cost of increased post-operative infection. While use of
section of six of the nine trials the trialists felt that it was generally
phenol will be most appropriate and beneficial for the majority of
preferable to use phenol, two felt it made no difference and one
people, risks and benefits should be discussed with each patient.
did not comment.
In the trials where patient satisfaction was recorded, methods of The evidence suggests that simple nail avulsion combined with the
assessing this were not described and any data should be regarded use of phenol, compared to surgical excisional techniques without
with caution. Three trials were excluded because of a follow-up of the use of phenol, is more effective at preventing symptomatic
less than six months. Although this meant that data were excluded, recurrence of ingrowing toenails. It should however be borne in
it was felt that this was justified, as symptomatic recurrence could mind that one trial (van der Ham 1990) had a large influence on
not be measured accurately in a time period of less than six months. the results.
Skill of the operator in performing the procedures is an important
consideration and was not taken into account by any of the trials.
Implications for research
All the trials were undertaken by general surgeons in a hospital
outpatient setting. This does not reflect the large number of pro- Further well designed trials are needed to confirm that the use of
cedures performed by other professionals, particularly those in the phenol on the nail matrix is preferable to nail matrix surgical ex-
community, for example general practitioners and podiatrists. cision. New trials should also examine short-term outcomes such
No trial attempted to measure cost effectiveness of each procedure. as healing time and pain as well as the primary outcome of recur-
This could be an important consideration if all other factors are rence.
found to be similar.
All trials were very inclusive in their criteria. Unfortunately we
were unable to analyse subgroups, for example, by age group (the
skin and healing of an adolescent is very different from that of
someone in their seventies) or by medical condition, for example, ACKNOWLEDGEMENTS
diabetes or mild ischaemia
Philip Alderson, UK Cochrane Centre
Iain Chalmers, UK Cochrane Centre
AUTHORS’ CONCLUSIONS Mark Lodge, Cochrane Cancer Network
REFERENCES
References to studies included in this review Issa 1988 {published data only}
Issa MM, Tanner WA. Approach to ingrowing toenails: the wedge
Anderson 1990 {published data only} resection/segmental phenolization combination treatment. British
Anderson JH, Greig JD, Ireland AJ, Anderson JR. Randomized, Journal of Surgery 1988;75:181–3.
prospective study of nail bed ablation for recurrent ingrowing
Leahy 1990 {published data only}
toenails. Journal of the Royal College of Surgeons of Edinburgh 1990;
Leahy AL, Timon CI, Craig A, Stephens RB. Ingrowing toenails:
35:240–2.
improving treatment. Surgery 1990;107:566–7.
Andrew 1979 {published data only}
Andrew T, Wallace WA. Nail bed ablation - excise or cauterise?A Morkane 1984 {published data only}
controlled study. British Medical Journal 1979;1:1539. Morkane AJ, Robertson RW, Inglis GS. Segmental phenolization of
Sykes PA, Kerr R. Treatment of ingrowing toenails by surgeons and ingrowing toenails: a randomized controlled study. British Journal
chiropodists. Chiropodist 1988;43:224. of Surgery 1984;71:526–7.
Sykes PA, Kerr R. Treatment of ingrowing toenails by surgeons and
Tait 1987 {published data only}
chiropodists. Chiropodist 1988;43:224.
Tait GR, Tuck JS. Surgical or phenol ablation of the nail bed for
Greig 1991a {published data only} ingrowing toenails: a randomised controlled trial [published
Grieg JD, Anderson JH, Ireland AJ, Anderson JR. The surgical erratum appears in J R Coll Surg Edinb 1988 Apr;33(2):109].
treatment of ingrowing toenails (Study 1). Journal of Bone and Joint Journal of the Royal College of Surgeons of Edinburgh 1987;32:
Surgery. British Volume 1991;73:131–3. 358–60.
van der Ham 1990 {published data only} Wallace 1979b {published data only}
van der Ham AC, Hackeng CA, Yo TI. The treatment of ingrowing Wallace WA, Milne DD, Andrew T. Gutter treatment for ingrowing
toenails. A randomised comparison of wedge excision and phenol toenails (study 2). British Medical Journal 1979;2:168–71.
cauterisation. Journal of Bone and Joint Surgery. British Volume
1990;72:507–9. References to studies awaiting assessment
Varma 1983 {published data only} Sykes 1988b {published data only}
Varma JS, Kinninmonth AW, Hamer Hodges DW. Surgical wedge Sykes PA, Kerr R. Treatment of ingrowing toenails by surgeons and
excision versus phenol wedge cauterisation for ingrowing toenail. A chiropodists (study 2). Chiropodist 1988;43:224.
controlled study. Journal of the Royal College of Surgeons of
Sykes 1988c {published data only}
Edinburgh 1983;28:331–2.
Sykes PA, Kerr R. Treatment of ingrowing toenails by surgeons and
References to studies excluded from this review chiropodists (study 3). Chiropodist 1988;43:224.
Zaborszky 1997 {published data only}
Beaton 1990 {published data only} Zaborszky Z, Fekete L, Tauzin F, Orgovan G. Treatment of
Beaton DF, Kriss SM, Blacklay PF, Wood RF. Ingrowing toenails: a ingrowing toenail with segmental chemical ablation. Acta
patient evaulation of phenolisation versus wedge excision. Chirurgica Hungarica 1997;36(1-4):398–400.
Chiropodist 1990;45:62–4.
References to ongoing studies
Burssens 1987 {published data only}
Burssens P, Vereecken L, Van Loon C. [A comparative study of 2 Crawford 2001 {published and unpublished data}
treatment methods for onychocryptosis (ingrown toenail)]. Acta An evaluation of ingrowing toe nail surgery in primary care.
Chirurgica Belgica 1987;87:294–7. Ongoing study 01/01/2000.
Fulton 1994 {published data only} Thomson 2001 {published and unpublished data}
Fulton GJ, O’Donohoe MK, Reynolds JV, Keane FB, Tanner WA. A clinical and economic evaluation of toe nail surgery performed by
Wedge resection alone or combined with segmental phenolization podiatrists in the community and surgeons in the hospital setting: a
for the treatment of ingrowing toenail. British Journal of Surgery RCT. Ongoing study 01/06/99.
1994;81(7):1074–5.
Additional references
Gem 1990 {published data only}
Gem MA, Sykes PA. Ingrowing toenails: studies of segmental Bremmer 1976
chemical ablation. British Journal of Clinical Practice 1990;44: Bremmer DN, McCormick JC, Price MH, Hunter E. Ingrown
562–3. toenail: an evaluation of current treatment methods. Chiropodist
1976;31:330–5.
Goslin 1992 {published data only}
Goslin RW. A comparison of the dilution and non-dilution of penol DeLauro 1995
with alcohol following nail avulsions. The Foot 1992;2:225–8. DeLauro T. Onychocryptosis. Clinics in Podiatric Medicine and
Surgery 1995;12(2):201–13.
Greig 1991b {published data only}
Laxton 1995
Greig JD, Anderson JH, Ireland AJ, Anderson JR. The surgical
Laxton C. Clinical audit of forefoot surgery performed by registered
treatment of ingrowing toenails [Study 2]. Journal of Bone and Joint
medical practitioners and podiatrists. Journal of Public Health
Surgery 1991;73-B:131–3.
Medicine 1995;17(3):311–7.
Holt 1987 {published data only} Milwain 1998
Holt S, Tiwari I, Howell G. Phenolisation as an adjunct to Zadik’s Milwain. Ingrowing toenail surgery - a survey of current practice
procedure for ingrowing toenail and onychogryphosis. Journal of amongst GPs. 1998.
the Royal College of Surgeons of Edinburgh 1987;32:228–9.
Sykes 1986
Sykes 1988a {published data only} Sykes PA. Ingrowing toenails: Time for critical appraisal?. Journal
Sykes PA, Kerr R. Treatment of ingrowing toenails by surgeons and of the Royal College of Surgeons of Edinburgh 1986;31(5):300–4.
chiropodists. Chiropodist 1988;43:224. ∗
Indicates the major publication for the study

CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Anderson 1990
Methods Random allocation stated but method not specified
Participants All patients (31) attending general surgery departments of hospital who had undergone at least to previous
surgical procedures. Onychogryphosis was excluded. Age range 15 to 73.
Interventions Zad*k vs phenol and Zad*k
Outcomes Symptomatic recurrence

Total recurrence
Post-operative infection
Patient satisfaction
Notes
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Andrew 1979
Methods Allocation by odd/even hospital number
Participants 107 participants with either onchogryphosis or onychocryptosis
Interventions Phenolisation vs Zadik’s
Outcomes Recurrence
Further treatment required for recurrence
Average healing time
Notes
Risk of bias
Allocation concealment? No C - Inadequate

Greig 1991a
Participants 204 procedures on 168 participants referred to hospital during one year and for whom conservative
treatment had failed. Recurrent IGTNs were excluded. Participants who had had surgery previously were
excluded.
Interventions Partial nail avulsion vs total nail avulsion vs phenol

Total recurrence
Patient satisfaction
Notes
Risk of bias
Issa 1988
Methods Allocation by random numbers
Participants 170 procedures referred from general practitioners and accident and emergency departments. Age range
9 to 54 (mean 21.1). Male female ratio 2.7:1.
Interventions Phenol vs Winograd vs phenol and Winograd
Outcomes Recurrence (symptomatic or asymptomatic)

Pain duration
Pain intensity (linear pain analogue scale)
Notes
Risk of bias
Leahy 1990
Methods Allocation by sealed envelopes
Participants All participants (68) with symptoms for more than 1 month who were referred to hospital over a fixed 6
month period. Mean age: 24.

Leahy 1990 (Continued)
Interventions Phenol vs wedge excision

Asymptomatic recurrence
Degree of pain
Notes
Risk of bias
Allocation concealment? Yes A - Adequate
Morkane 1984
Participants 107 procedures on 103 participants referred from general practitioners and accident and emergency
departments who have had symptoms for longer than 2 months. participants who had undergone surgery
previously were excluded.
Mean age: 28.5 for phenol;
Interventions Phenol vs Winograd
Outcomes Recurrence (symptomatic or asymptomatic)

Pain intensity at one week (Wilcoxon Rank Sum Test used)
Notes
Risk of bias
Tait 1987
Methods Allocation by date of birth
Participants All participants referred to hospital from general practitioners, accident and emergency and surgical clinics
during fixed nine month period. Ninety-five procedures compared (14 lost to follow-up)
Interventions Phenol vs wedge excision

Tait 1987 (Continued)

Asymptomatic recurrence
Pain duration
Healing time
Notes
Risk of bias
Allocation concealment? No C - Inadequate
van der Ham 1990
Methods Randomisation by sealed envelopes
Participants 249 participants referred by general practitioners. participants who had undergone previous surgery were
excluded. Age range 3 to 97.
Interventions Phenol vs Winograd
Outcomes Recurrence
Re-operation required
Healing time
Pain relief required
Time required off work
Notes
Risk of bias
Varma 1983
Methods Consecutive randomised envelopes
Participants 67 participants undergoing IGTN surgery during a fixed 8 months period.
Interventions Standard surgical wedge excision vs phenol wedge cauterisation

Varma 1983 (Continued)
Outcomes Symptomatic recurrence at least six months

Total recurrence
Healing time
Notes
Risk of bias
IGTN = ingrowing toenail
Characteristics of excluded studies [ordered by study ID]
Beaton 1990 Follow-up only three months
Burssens 1987 Follow-up not necessarily > six months. Although the mean follow-up was 12 months, some participants were
followed up after only 4 months
Fulton 1994 Not prospective
Gem 1990 Very large loss to follow-up (>30%)
Goslin 1992 Follow-up less than six months
Greig 1991b Study 2 - observational study - not comparing interventions
Holt 1987 Follow-up only three months
Sykes 1988a Not a trial - No comparison groups
Wallace 1979b Gutter treatment does not fulfil inclusion criteria as does not remove troublesome portion of the nail.

Characteristics of ongoing studies [ordered by study ID]
Crawford 2001
Trial name or title An evaluation of ingrowing toe nail surgery in primary care
Methods
Participants
Interventions
Outcomes
Starting date 01/01/2000
Contact information
Notes
Thomson 2001
Trial name or title A clinical and economic evaluation of toe nail surgery performed by podiatrists in the community and surgeons
in the hospital setting: a RCT
Methods
Participants
Interventions
Outcomes
Starting date 01/06/99
Contact information
Notes Complete - awaiting write up and 12 month follow-up

DATA AND ANALYSES
Comparison 1. PHENOL AND AVULSION vs SURGICAL PROCEDURES
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Symptomatic recurrence at 6 5 585 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.44 [0.24, 0.80]
months or more
1.1 Zad*k’s 1 107 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.33 [0.10, 1.11]
1.2 Winograd 1 249 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.25 [0.09, 0.66]
1.3 Wedge/segmental excision 3 229 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.94 [0.35, 2.50]
2 Asymptomatic recurrence at least 2 166 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.95 [0.45, 2.00]
6 months
2.1 Zad*k’s 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
2.2 Winograd 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
3 Recurrence at 6 months or more 6 719 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.54 [0.36, 0.79]
3.1 Zad*k’s 1 107 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.37 [0.16, 0.90]
3.2 Winograd 3 464 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.43 [0.25, 0.73]
4 Pain duration Other data No numeric data
4.1 Zad*k’s Other data No numeric data
4.2 Winograd Other data No numeric data
4.3 Wedge/segmental excision Other data No numeric data
5 Pain intensity Other data No numeric data
6 Healing time Other data No numeric data
7 Patient dissatisfied with 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
procedure
7.3 Wedge/segmental excision 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
8 Post operative infection 2 147 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.60 [0.24, 1.50]

Comparison 2. PHENOL AND SURGERY vs SURGERY
No. of No. of
months or more
1.1 Zad*k’s and phenol vs 1 31 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.31 [0.05, 2.05]
zad*k’s
1.2 Winograd and phenol vs 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
winograd
and phenol vs wedge/segmental
excision
2 Asymptomatic recurrence at at 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
least 6 months
2.1 Zad*k’s and phenol vs 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
zad*k’s
winograd
excision
zad*k’s
winograd
excision
4.1 Zad*k’s and phenol vs Other data No numeric data
zad*k’s
4.2 Winograd and phenol vs Other data No numeric data
winograd
excision
5.1 Zad*k’s and phenol vs Other data No numeric data
zad*k’s
5.2 Winograd and phenol vs Other data No numeric data
winograd
excision
6 Healing time 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
6.1 Zad*k’s and phenol vs 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
zad*k’s
6.2 Winograd and phenol vs 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
winograd
6.3 Wedge/segmental excision 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
excision
7 Patient dissatisfied with 1 31 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.16 [0.00, 8.29]
procedure
zad*k’s
winograd
excision
zad*k’s
winograd
excision
Comparison 3. PHENOL AND AVULSION vs PHENOL AND SURGERY
No. of No. of
1 Symptomatic recurrence at 6 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
months or more
1.1 Phenol vs Zad*k’s and 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
phenol
1.2 Phenol vs Winograd and 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
phenol
1.3 Phenol vs wedge/ 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
segmental excision and phenol
least 6 months
phenol
phenol
phenol
3.2 Phenol vs Winograd and 1 115 Peto Odds Ratio (Peto, Fixed, 95% CI) 9.29 [1.27, 68.09]
phenol
4.1 Phenol vs Zad*k’s and Other data No numeric data
phenol
4.2 Phenol vs Winograd and Other data No numeric data
phenol
4.3 Phenol vs wedge/ Other data No numeric data
5.1 Phenol vs Zad*k’s and Other data No numeric data
phenol
5.2 Phenol vs Winograd and Other data No numeric data
phenol
5.3 Phenol vs wedge/ Other data No numeric data
6 Healing time 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
6.1 Phenol vs Zad*k’s and 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
phenol
6.2 Phenol vs Winograd and 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
phenol
6.3 Phenol vs wedge/ 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
7 Patient dissatisfied with 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
procedure
phenol
phenol
8 Post operative infection 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
phenol
phenol
Comparison 4. PHENOLISATION AND AVULSION vs SIMPLE AVULSION
No. of No. of
months or more
1.1 Total nail avulsion 1 116 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.07 [0.03, 0.14]
1.2 Partial nail avulsion 1 93 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.08 [0.04, 0.18]
least 6 months
2.1 Total nail avulsion 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
2.2 Partial nail avulsion 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
4.1 Total nail avulsion Other data No numeric data
4.2 Partial nail avulsion Other data No numeric data
6 Healing time Other data No numeric data
7 Patient dissatisfied with 1 220 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.19 [0.11, 0.34]
procedure

Analysis 1.1. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 1
Symptomatic recurrence at 6 months or more.
Review: Surgical treatments for ingrowing toenails
Comparison: 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES
Outcome: 1 Symptomatic recurrence at 6 months or more
Study or subgroup phenol surgery Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
1 Zad*k’s
Andrew 1979 3/53 9/54 25.2 % 0.33 [ 0.10, 1.11 ]
Subtotal (95% CI) 53 54 25.2 % 0.33 [ 0.10, 1.11 ]

Total events: 3 (phenol), 9 (surgery)
Heterogeneity: not applicable
Test for overall effect: Z = 1.80 (P = 0.073)
2 Winograd
van der Ham 1990 3/125 14/124 37.3 % 0.25 [ 0.09, 0.66 ]
Subtotal (95% CI) 125 124 37.3 % 0.25 [ 0.09, 0.66 ]

3 Wedge/segmental excision
Leahy 1990 4/39 2/46 13.1 % 2.44 [ 0.46, 12.75 ]
Tait 1987 1/43 1/38 4.6 % 0.88 [ 0.05, 14.43 ]
Varma 1983 3/28 7/35 19.8 % 0.50 [ 0.13, 1.94 ]
Subtotal (95% CI) 110 119 37.5 % 0.94 [ 0.35, 2.50 ]

Heterogeneity: Chi2 = 2.09, df = 2 (P = 0.35); I2 =4%
Total (95% CI) 288 297 100.0 % 0.44 [ 0.24, 0.80 ]
Test for subgroup differences: Chi2 = 3.79, df = 2 (P = 0.15), I2 =47%
0.05 0.2 1 5 20
Favours phenol Favours surgery

Asymptomatic recurrence at least 6 months.
Outcome: 2 Asymptomatic recurrence at least 6 months
Study or subgroup Phenol Surgery Peto Odds Ratio Weight Peto Odds Ratio
1 Zad*k’s
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol), 0 (Surgery)
Test for overall effect: not applicable
2 Winograd
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Leahy 1990 7/39 10/46 49.2 % 0.79 [ 0.27, 2.28 ]
Tait 1987 10/43 8/38 50.8 % 1.13 [ 0.40, 3.22 ]
Subtotal (95% CI) 82 84 100.0 % 0.95 [ 0.45, 2.00 ]

Heterogeneity: Chi2 = 0.23, df = 1 (P = 0.64); I2 =0.0%
Total (95% CI) 82 84 100.0 % 0.95 [ 0.45, 2.00 ]
0.1 0.2 0.5 1 2 5 10

Favours phenol FavFavours surgery

Recurrence at 6 months or more.
Outcome: 3 Recurrence at 6 months or more
1 Zad*k’s
Andrew 1979 8/53 18/54 19.3 % 0.37 [ 0.16, 0.90 ]
Subtotal (95% CI) 53 54 19.3 % 0.37 [ 0.16, 0.90 ]

2 Winograd
Issa 1988 4/53 7/55 9.7 % 0.57 [ 0.16, 1.97 ]
Morkane 1984 4/54 16/53 15.9 % 0.23 [ 0.09, 0.60 ]
van der Ham 1990 12/125 20/124 27.2 % 0.56 [ 0.27, 1.17 ]
Subtotal (95% CI) 232 232 52.8 % 0.43 [ 0.25, 0.73 ]

Leahy 1990 11/39 12/46 16.4 % 1.11 [ 0.43, 2.89 ]
Varma 1983 7/28 9/35 11.6 % 0.96 [ 0.31, 2.99 ]
Subtotal (95% CI) 67 81 28.0 % 1.05 [ 0.50, 2.17 ]

Total (95% CI) 352 367 100.0 % 0.54 [ 0.36, 0.79 ]
Test for subgroup differences: Chi2 = 4.57, df = 2 (P = 0.10), I2 =56%
0.1 0.2 0.5 1 2 5 10

Analysis 1.4. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 4 Pain
duration.
Pain duration
Winograd

Pain duration (Continued)
van der Ham 1990 Phenol: Mean 0.4 days

Winograd: Mean 1.1days
Wedge/segmental excision
Tait 1987 Phenol: 2.25 days

Excision: 2.3 days
Analysis 1.5. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 5 Pain
intensity.
Pain intensity
Leahy 1990 1 (out of 32) patient found phenol treatment unacceptably painful. 2 (out of 34) patients found the
surgical excision unacceptably painful
Analysis 1.6. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 6 Healing
time.
Healing time
Zad*k’s
Andrew 1979 Phenol: average 3 weeks for cryptosis, 2 weeks for gryphosis
Zadik’s: average 4 weeks for cryptosis, 2 weeks for gryphosis
Winograd
van der Ham 1990 Phenol: Mean 2.2 weeks

Winograd: Mean 2.5 weeks
Tait 1987 Phenol: 28.3 days

Excision: 21.8 days

Analysis 1.8. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 8 Post
operative infection.
Outcome: 8 Post operative infection
1 Zad*k’s
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
2 Winograd
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Leahy 1990 4/32 3/34 34.0 % 1.47 [ 0.31, 6.94 ]
Tait 1987 5/43 10/38 66.0 % 0.38 [ 0.13, 1.17 ]
Subtotal (95% CI) 75 72 100.0 % 0.60 [ 0.24, 1.50 ]

Total (95% CI) 75 72 100.0 % 0.60 [ 0.24, 1.50 ]
0.1 0.2 0.5 1 2 5 10


Analysis 2.1. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 1 Symptomatic recurrence
at 6 months or more.
Comparison: 2 PHENOL AND SURGERY vs SURGERY
Study or subgroup Phenol and surgery Surgery Peto Odds Ratio Weight Peto Odds Ratio
1 Zad*k’s and phenol vs zad*k’s

Anderson 1990 1/14 4/17 100.0 % 0.31 [ 0.05, 2.05 ]
Subtotal (95% CI) 14 17 100.0 % 0.31 [ 0.05, 2.05 ]

Total events: 1 (Phenol and surgery), 4 (Surgery)
2 Winograd and phenol vs winograd
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
3 Wedge/segmental excision and phenol vs wedge/segmental excision
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total (95% CI) 14 17 100.0 % 0.31 [ 0.05, 2.05 ]
0.05 0.2 1 5 20
Favours phenol % su Favours surgery

Analysis 2.3. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 3 Recurrence at 6 months or
more.

Anderson 1990 6/14 10/17 100.0 % 0.54 [ 0.13, 2.17 ]
Subtotal (95% CI) 14 17 100.0 % 0.54 [ 0.13, 2.17 ]

Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total (95% CI) 14 17 100.0 % 0.54 [ 0.13, 2.17 ]
0.1 0.2 0.5 1 2 5 10

Favours phenol and s Favours surgery

Analysis 2.7. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 7 Patient dissatisfied with
procedure.
Outcome: 7 Patient dissatisfied with procedure

Anderson 1990 0/14 1/17 100.0 % 0.16 [ 0.00, 8.29 ]
Subtotal (95% CI) 14 17 100.0 % 0.16 [ 0.00, 8.29 ]

Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total (95% CI) 14 17 100.0 % 0.16 [ 0.00, 8.29 ]
0.005 0.1 1 10 200


Analysis 2.8. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 8 Post operative infection.

Anderson 1990 1/14 7/14 100.0 % 0.13 [ 0.03, 0.66 ]
Subtotal (95% CI) 14 14 100.0 % 0.13 [ 0.03, 0.66 ]

Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total (95% CI) 14 14 100.0 % 0.13 [ 0.03, 0.66 ]
0.02 0.1 1 10 50

Analysis 3.3. Comparison 3 PHENOL AND AVULSION vs PHENOL AND SURGERY, Outcome 3
Comparison: 3 PHENOL AND AVULSION vs PHENOL AND SURGERY
Study or subgroup Phenol Phenol and surgery Peto Odds Ratio Weight Peto Odds Ratio
1 Phenol vs Zad*k’s and phenol

Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol), 0 (Phenol and surgery)
2 Phenol vs Winograd and phenol
Issa 1988 4/53 0/62 100.0 % 9.29 [ 1.27, 68.09 ]
Subtotal (95% CI) 53 62 100.0 % 9.29 [ 1.27, 68.09 ]

3 Phenol vs wedge/segmental excision and phenol
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total (95% CI) 53 62 100.0 % 9.29 [ 1.27, 68.09 ]
0.01 0.1 1 10 100

Favours phenol Favours phenol % sur

Analysis 4.1. Comparison 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION, Outcome 1
Symptomatic recurrence at 6 months or more.
Comparison: 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION
Study or subgroup Phenol Simple avulsion Peto Odds Ratio Weight Peto Odds Ratio
1 Total nail avulsion

Greig 1991a 6/57 46/59 55.4 % 0.07 [ 0.03, 0.14 ]
Subtotal (95% CI) 57 59 55.4 % 0.07 [ 0.03, 0.14 ]

Total events: 6 (Phenol), 46 (Simple avulsion)
Test for overall effect: Z = 7.27 (P < 0.00001)
2 Partial nail avulsion
Greig 1991a 6/46 36/47 44.6 % 0.08 [ 0.04, 0.18 ]
Subtotal (95% CI) 46 47 44.6 % 0.08 [ 0.04, 0.18 ]

Total (95% CI) 103 106 100.0 % 0.07 [ 0.04, 0.12 ]
Test for subgroup differences: Chi2 = 0.09, df = 1 (P = 0.77), I2 =0.0%
0.02 0.1 1 10 50
Favours phenol Favours avulsion


Greig 1991a 6/57 59/59 52.8 % 0.03 [ 0.01, 0.06 ]
Subtotal (95% CI) 57 59 52.8 % 0.03 [ 0.01, 0.06 ]

Greig 1991a 6/57 41/47 47.2 % 0.05 [ 0.02, 0.10 ]
Subtotal (95% CI) 57 47 47.2 % 0.05 [ 0.02, 0.10 ]

Total (95% CI) 114 106 100.0 % 0.04 [ 0.02, 0.06 ]
0.1 0.2 0.5 1 2 5 10


Patient dissatisfied with procedure.
Outcome: 7 Patient dissatisfied with procedure

Greig 1991a 9/57 32/59 54.3 % 0.19 [ 0.09, 0.40 ]
Subtotal (95% CI) 57 59 54.3 % 0.19 [ 0.09, 0.40 ]

Greig 1991a 9/57 24/47 45.7 % 0.20 [ 0.09, 0.46 ]
Subtotal (95% CI) 57 47 45.7 % 0.20 [ 0.09, 0.46 ]

Total (95% CI) 114 106 100.0 % 0.19 [ 0.11, 0.34 ]
0.1 0.2 0.5 1 2 5 10


Analysis 4.8. Comparison 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION, Outcome 8 Post
operative infection.

Greig 1991a 7/57 0/59 50.4 % 8.56 [ 1.87, 39.22 ]
Subtotal (95% CI) 57 59 50.4 % 8.56 [ 1.87, 39.22 ]

Greig 1991a 6/57 1/47 49.6 % 3.76 [ 0.81, 17.44 ]
Subtotal (95% CI) 57 47 49.6 % 3.76 [ 0.81, 17.44 ]

Total (95% CI) 114 106 100.0 % 5.69 [ 1.93, 16.77 ]
0.02 0.1 1 10 50
APPENDICES
Appendix 1. Electronic search terms

Keywords:
INGROWING TOENAIL*
ONYCHOGRYPHOSIS
ONYCHOCRYPTOSIS
CHEMICAL ABLATION
PHENOL*
ZADEK*
ZADIK*
ZADECK*
WINOGRAD*
WEDGE RESECTION
WEDGE EXCISION
NAIL BED ABLATION
NAIL BED EXCISION
NAIL MATRIX
CRYO*
INVOLUTED TOENAIL*
HYDROGEN PEROXIDE
NITROUS OXIDE
SALICYLIC ACID
FEEDBACK
Comment received 9 December 1999
Summary
Comment 1
This is an interesting and useful review, but I think the inclusion criteria
should be modified so that in the next revision any trial comparing a
surgical treatment with another treatment, whether surgical or not, is
included. In practice the doctor and patient have to choose between all the
treatments on offer, not just between different surgical treatments. There
is no a priori reason why a treatment should aim to remove part or all of a
nail. The trial by Wallace et al which was excluded, compares the much
simpler and easier gutter treatment with surgery, and was worthwhile even
though it was effective in a lower proportion of cases.
Comment 2
In the authors’ view, what other reviews are needed? It would be good to
have a comment on this in the conclusion under ’Implications for research.
Comment 3
The paragraph on ’Implications for research’ should be expanded to include
estimation of the cost-effectiveness of the different treatments, and of
their effects on various aspects of disability (eg time off work, ability to
walk normally, need for follow-up visits).
Comment 4
Did any consumers or participants with experience of ingrowing toenail comment
on the review? Did any chiropodist do so? If so, this should be said; if
not, such comments should be solicited and used to strengthen the review.

Reply
Comment 1
Conservative treatment is successful for most cases for ingrowing toenails.
Surgery is generally chosen as a 2nd line of treatment after more
conservative treatments have already been tried and failed. I wouldn’t
expect to find trials comparing a surgical treatment to a more conservative
treatment because ethically, where possible, a conservative treatment should
be tried, before involving the patient in invasive surgery.
While there is scope to evaluate conservative treatments, I think this
should be done as a separate review.
Comment 2
On the theme of surgery for ingrowing toenails I have a couple of ideas for
useful reviews:
1. comparison of operators eg general surgeon versus podiatrist on
recurrence, cost and complication rates.
2. post-operative care of wounds (particularly after phenolisation).
On foot care generally there are a huge number of reviews which would be
useful, although those done recently on diabetic foot health are very
important. If choosing one area to review, I think the impact of the free
availability of podiatry services on the well-being of elderly people would
be particularly useful to funders.
Comment 3
Yes, fair comment. I had mentioned these factors in the discussion and on
reflection, do think I can justify adding them to ’Implications for research.
Comment 4
C. Rounding is an ex-chiropodist and S. Bloomfield is a practising
chiropodist. L. Gliddon, who had an ingrowing toenail, commented on the
review for readability and relevance. A practising chiropodist acted as a
content referee for the protocol and final review.
Contributors
Comment sent by:
Andrew Herxheimer
Reply from:
Catherine Rounding (lead reviewer)
Processed by:
Urbà González, Cochrane Skin Group Criticisms Editor
Tina Leonard, Review Group Co-ordinator for the Cochrane Skin Group

WHAT’S NEW
Last assessed as up-to-date: 27 October 2002.
12 June 2008 Amended Converted to new review format.
HISTORY
Protocol first published: Issue 2, 1999
Review first published: Issue 3, 1999
18 November 2002 Amended Minor update
29 October 2002 Feedback has been incorporated Response to feedback added
29 October 2002 Feedback has been incorporated Feedback added
28 October 2002 New citation required and conclusions have changed Substantive amendment
28 October 2002 New search has been performed New studies sought but not found
28 November 2000 New search has been performed New studies found and included or excluded
20 November 2000 New search has been performed New studies found but not yet included or excluded
30 September 1999 Amended Reformatted
DECLARATIONS OF INTEREST
None known
NOTES
This review is currently being updated by a new team of authors. Until this update is published, please be aware that this review was
last assessed as up-to-date in 2002.

INDEX TERMS
Medical Subject Headings (MeSH)
Combined Modality Therapy; Nails, Ingrown [prevention & control; ∗ surgery]; Phenol [therapeutic use]; Randomized Controlled
Trials as Topic; Recurrence [prevention & control]; Toes
MeSH check words

Humans


Cochrane - Phenol

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Cochrane - Phenol

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Surgical treatments for ingrowing toenails (Review)

Surgical treatments for ingrowing toenails (Review)

Surgical treatments for ingrowing toenails (Review) i

Surgical treatments for ingrowing toenails

Catherine Rounding1 , Sally Bloomfield2

Editorial group: Cochrane Skin Group.

PLAIN LANGUAGE SUMMARY

Surgical interventions for ingrowing toenails

Description of the condition Description of the intervention

Search methods for identification of studies

Surgical treatments for ingrowing toenails (Review) 3

Surgical treatments for ingrowing toenails (Review) 4

Surgical treatments for ingrowing toenails (Review) 5

Iain Chalmers, UK Cochrane Centre

AUTHORS’ CONCLUSIONS Mark Lodge, Cochrane Cancer Network

Surgical treatments for ingrowing toenails (Review) 7

Characteristics of included studies [ordered by study ID]

Methods Random allocation stated but method not specified

Interventions Zad*k vs phenol and Zad*k

Outcomes Symptomatic recurrence

Item Authors’ judgement Description

Allocation concealment? Unclear B - Unclear

Methods Allocation by odd/even hospital number

Participants 107 participants with either onchogryphosis or onychocryptosis

Interventions Phenolisation vs Zadik’s

Item Authors’ judgement Description

Allocation concealment? No C - Inadequate

Surgical treatments for ingrowing toenails (Review) 8

Methods Random allocation stated but method not specified

Interventions Partial nail avulsion vs total nail avulsion vs phenol

Outcomes Symptomatic recurrence

Item Authors’ judgement Description

Allocation concealment? Unclear B - Unclear

Methods Allocation by random numbers

Interventions Phenol vs Winograd vs phenol and Winograd

Outcomes Recurrence (symptomatic or asymptomatic)

Item Authors’ judgement Description

Allocation concealment? Unclear B - Unclear

Methods Allocation by sealed envelopes

Surgical treatments for ingrowing toenails (Review) 9

Interventions Phenol vs wedge excision

Outcomes Symptomatic recurrence

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Methods Random allocation stated but method not specified

Interventions Phenol vs Winograd

Outcomes Recurrence (symptomatic or asymptomatic)

Item Authors’ judgement Description

Allocation concealment? Unclear B - Unclear

Methods Allocation by date of birth

Interventions Phenol vs wedge excision

Surgical treatments for ingrowing toenails (Review) 10

Outcomes Symptomatic recurrence

Item Authors’ judgement Description

Allocation concealment? No C - Inadequate

van der Ham 1990

Methods Randomisation by sealed envelopes

Interventions Phenol vs Winograd

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Methods Consecutive randomised envelopes

Participants 67 participants undergoing IGTN surgery during a fixed 8 months period.

Interventions Standard surgical wedge excision vs phenol wedge cauterisation

Interventions Zadk vs phenol and Zadk

1 Zadk’s and phenol vs zadk’s

1 Zadk’s and phenol vs zadk’s