Pearls and Pitfalls of Phenolic Nail Surgery

The infected toe nail

Pearls and pitfalls of phenol nail surgery are addressed in this article. A diversity of questions arise from a podiatry facebook page and ConsultingFootPain is delighted to pick up comments and put them into a single article to avoid fragmentation. The subject relates to the all too common query about ingrowing toe nails and their failure to respond to treatment. There can be no greater reflection than reading answers from professional podiatrists offering a wide range of experience. This article is based around nasty looking toes that won’t seem to heal.  Of course if it is Covid toe check symptoms and test the patient for the corona virus. There are now two narratives to this tale…

The ingrown nail that recurs after phenolisation. And the diabetic and at risk patient. Should we treat diabetics in the same way as non-diabetic patients? The subject is based around ‘phenol’ but there are some hidden golden nuggets.

Reading score = 59 ‘professional’


Recalcitrant onychocryptoses

There are three ways to deal with a toe nail that causes characteristic inflammation, the cherry red covering of hypergranulation, pain, suppuration and offensive odour. The questions we must ask are… 

To treat conservatively, to apply a chemical to destroy the growth cells called the matrix, or remove a soft section of the toe?

 

History has dictated the pathway chosen

Astonished and frustrated by the medical profession’s ineptitude, the profession did the unexpected and learned the art of anaesthesia, called local analgesia. This not only made dealing with nail problems more comfortable but allowed us to import the skill to undertake nail destruction. Podiatrists in the sixties and seventies Britain learned to remove a controlled amount of nail. Over the course of the next 25 years the success has been well established illuminating one technique over others. Podiatrists do it better than any other professional was evidence by Dr Clare Laxton’s article in 1985 when comparing traditional medical intervention using phenol with that of podiatrists. As with all skills, the more exposure and the more one does, expertise genuinely develops. But do we rely on one technique too much? Does one method fit all? 


Pearls and Pitfalls Using Phenol

The diversity of the query comes from the point when a clinician is unsure what to do for the best. Three scenarios provide a composite view and options:- patients present as follows

  1. with known medical problems and diabetes. 
  2. reoccurring regrowth after several attempts
  3. where having treated a regrowth with antibiotics and nail surgery, the toe nail continues to look nasty

Case 1 – Reflection on MEDICAL RISK

In case (1) there is a dilemma. The clinician wants to use phenol but is unsure if the phenol could put the patient at risk. Advice was wide and varied from a Facebook audience. Majority believed that if the circulation is fine and the blood analysis for diabetes stable, phenol should be fine. The corollary is that the patient should be informed of the risks and all is implied that this will safeguard a decision. Here are three counter corollaries. 

All tissue is different and because healing is the concern, phenol can impede healing. This recalcitrance to recover say within a 10-21 day period can be extended for months. There is straight forward answer to any person wondering whether to proceed. This is taken from a post (Berms 2008) from a different podiatry UK site.

(I) Have done probably 150 or more nail procedures/surgeries in the last 5-10 yrs, haven’t had any real adverse reactions or complications so far. However, I did a partial nail avulsion and chemical cautery (with phenol) on the left Hallux nail of a healthy 12yr old. She had no reported allergies and no regular medication… She is complaining of a lot of pain post-op (4 days) and has a large “white area” (her words) around the wound site? The original phenol was flushed with alcohol and the toe was dressed with povidone iodine ointment. She has been redressing herself since day 3. She is coming in today for me to have a look, but I thought I might get an idea of what I might be looking at? I have had some phenol reactions before, but they are usually small and red in colour.
Any advice is appreciated. Berms, Apr 30, 2008

I was asked where was the evidence?

The question sought suggested that phenol could have a lethal effect. Months of despair, dressings, depression, loss of limb and maybe death.

The response from Podiatry Arena suggests that risks are low. There has been a presumption that one can use a specific ‘duration time’ for every patient. This is taught in undergraduate school and it is broadly correct but for one fact. All tissue is made up to a specific DNA recipe and therefore allergies, sensitivities and reactions to what is afterall a caustic burn can arise. IF there is an unknown, one should remove that risk. You have to deal with pain and infection and healing. Remove the section or whole nail and let it reoccur but monitor the healing. Remove the risk from unknown phenol reactions.

My colleague and I ran a surgery programme and we took this same view. If in doubt do less. Sadly on one occasion we noted a case of a diabetic (that we had not operated on) who went onto have a leg amputation following a phenolisation. Without question this was the problem created by phenol saturation. That was nearly 30 years ago but in a career spanning over 40 years, I have seen delayed healing, burns and skin damage due to accidental phenol application elsewhere. The literature is not particularly good at recording evidence and this is where case history, a bit like case law, comes in. The US magazine journal Podiatry Today has a recent article (2020) of interest but does not open up the debate despite being recent. Many citations are old and the newest was 2015. Turning to the College of Podiatry database PASCOM data does not sustain sequellae in large numbers. We conclude that regrowth, infection and other such problems are low? In other words we are taking it as read that this IS THE CASE when in fact much under reporting probably exists.

This could well be true but IF clinicians are not using PASCOM. PASCOM is free to use for College of Podiatry members but any paucity in data creates a yawning gap. Many fear reporting problems reflects badly on their own ability. If you think this is the case then read my article Become a Black Box Thinker. It has taken years to persuade doctors and podiatric surgeons to record all their sequellae. We only learn when data is robust. So evidence is scanty but it is there.

In a 5 year data capture n= 61 nail phenolisation cases from ALL groups had a regrowth of 2.1%. However in the smaller number of 26 cases who had diabetes alone, 10.3% had a recorded infection and 5.1% had regrowth with phenol. Source PASCOM accessed 19/01/21

Case 2 – Reflection ON THE GROUNDS OF INCORRECT SELECTION

Where phenol surgery has failed it is easy to suggest that the clinician is at fault. There are reasons that phenol can fail. There is a case that some patients just do not respond to this form of management. Two attempts would seem reasonable before taking on the alternative such as a nail matricectomy by resection and suture. Never be afraid to say I cannot, don’t know. The basis of Hippocrates’ Oath can be trimmed down to two associated clauses:

I swear to fulfill, to the best of my ability and judgment, this covenant: …I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
…I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.


Case 3 – Reflection BASED ON POOR HEALING

The case of a patient having poor healing and infection was more enlightening in the most recent spin on this topic. The responses came back as most likely S.Aureus which is true but there is a case for focal infection that can be overlooked. Secondly and more bizarre is the self-harm side. If antibiotics fail they do so because of the wrong dose, the wrong antibiotic for the organism present. In this case scenario the author found a patient failed to respond. Culture is mandatory in these circumstances. In one of my own cases 8 year ago, Flucloxacillin PO 500mg qds was prescribed but failed. Prevotalla melaningenica was identified arising from a dental gum infection and treated with metronidazole when it then cleared. This was put down to focal infection.

The second case of non healing occurred where the young female patient (adolescent) had a case of onychotillomania, i.e picked at her nail tissue obsessively. Never underestimate neuroses surrounding conditions that do not seem to do well.


Facebook Query Series

Summary

Evidence is important and always will be. PASCOM data is far from ideal and needs to be collected prospectively with tighter controls. There again PASCOM provides clinicians with support to help reflect on their practice as was always intended. Modha (2018) provided a useful insight into the system for nail surgery capture.

We take home that healing problems are not down the clinician alone. Problems may be associated with different tissue types. No study to date has provided a conclusive distinction between tissue types, But, the female – male gender gap in health is more relevant now than ever. Likewise for the sake of avoiding risk, stay safe and do not use phenol if uncertain. Despite the apparent low risk it may appear low but we cannot rely on small data sets without robust scientific technique. Poor healing may be down to the patient or a focal infection.

Read about Alison’s case about pain after injections


Thanks for reading this Facebook series –  “Pearls and Pitfalls of Phenolic Nail Surgery” by David R Tollafield

Published by Busypencilcase Reflective Communications Est. 2015


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Published 25 February 2021