About This Blog & My Experience

What: This blog is information on phenol toenail ablation (chemical matricectomy with phenol) from medical resources and my personal experience. I had my right big toenail permanently removed with phenol ablation a year prior; these posts are about the remaining 9 toenails I had permanently removed.

Why: The reason I'm posting this is because I had trouble finding information on what to expect for surgery, pain, recovery time (8+ weeks), bandaging, and how to deal with walking. Also, for those considering permanent toenail removal I wanted to share my positive experience and say how great this life-changing procedure was.

Who: I am a medical resident who spends a significant amount of time on my feet. My toenail problems began when I started working on-call shifts during medical school. These shifts can last up to 30-hours and most of the time I am on my feet. I had my right big toenail removed during medical school after visiting a podiatrist for an infected ingrown. When the ingrown toenails kept recurring on different toes and I realized I could not do my job without being on my feet all the time, the decision was made with my podiatrist to remove all my toenails permanently with phenol ablation. I have absolutely no regrets.

Surgery: Done at a surgical center under sedation with local anesthetic, hobbled out pain-free shortly after.
Pain: "Bad" pain Days 0 - 1, "Mild" pain Days 2 - 7, "Bad" pain Days 8 - 12, "Horrendous" pain Days 13 - 20, Improved after.
Bandaging: Gauze + Band-Aids work great, Open Air (no bandages but moist wound) whenever reasonable, Band-Aids alone during first week was a really bad idea.
Walking: Open-toe surgical boots were perfect, loose fitting tennis shoes possible if toes properly bandaged, normal work/dress shoes nearly impossible until Day 24.
Drainage: Lots of drainage Days 0 - 14, Mild drainage Days 15 - 24 (socks only mildly wet), Improved after.
Healing: Able to walk normally without shuffling on Day 24, Wounds looked great around Day 24 and were level with surrounding toe, Improved after.

Single Toenail Removal
: As a side note, the experience was much different when I had a single big toenail removed. The draining was easier to manage and the pain wasn't bad. I was able to wear normal shoes as well, which is something I could not do for the first three weeks after having the remaining 9 toenails removed. The worst part of having the single toenail removed was the local anesthetic at the podiatrist's office.

About Phenol Toenail Ablation

Post-Surgery Information (from podiatrist)
* Soak toe/foot in lukewarm soapy water for 30 minutes once or twice a day.
* Replace bandage daily. Keep wound moist at all times. Do not let it dry.
* Redness, swelling, and clear drainage is normal.
* You may bathe/shower normally. If it does not cause pain, you may gently wash across the surgical site.
* Some bleeding through the bandage is normal, if excessive then elevate foot above heart level. Add additional bandages if still bleeding, contact surgical office if bleeding does not stop.
* Your doctor may give you pain medication for comfort. If not, take aspirin or Tylenol as directed.
* Under most circumstances, a partial nail procedure will heal in 3-4 weeks. A total nail procedure will heal in 8 weeks or more.

Procedure Information (from UpToDate)
Introduction
: Nail disorders, particularly ingrown, incurved, pincer, hypertrophic, infected, and painful nails, are common conditions in adults. Although abnormalities of nails can be disfiguring, it is usually pain that brings the patient to the physician. Most asymptomatic nail disorders affect the toenails, but the fingernails can be affected as well.

Chemical Matricectomy: Chemical matricectomy is the chemical ablation of all or part of the nail matrix. The rationale for chemical matricectomy is to destroy the matrix to prevent the nail from growing. Typical indications are recurrent or chronically ingrown, or incurved, nails with frequent pain or infection. Previously, surgical resections of the nail matrix also involved amputation of underlying bone and were associated with long healing times and disfigurement. The current procedure of chemical ablation is relatively easy to perform, has minimal bleeding, allows the patient to return to normal activities after a few days, is not significantly disfiguring and compares favorably to surgical approaches with recurrence rates of less than 5 percent.

Procedure: To perform the procedure, the digit must be well anesthetized with a digital block and soaked in the antiseptic solution. The nail plate is partially avulsed if just a portion of the matrix is to be ablated or completely avulsed if the entire matrix is to be ablated. Any exuberant tissue should be curetted or excised with scissors and forceps. The area of matrix to be treated is then curetted sharply. A tourniquet is then placed at the base of the digit to prevent blood from diluting the phenol. The overlying proximal nail fold, adjacent nail bed, and lateral nail folds are then coated with petroleum jelly to prevent phenol from damaging these tissues.

Cotton-tipped applicators are stripped of all but a small wisp of cotton, or alternatively, the bare end of the stick is covered with a small wisp of cotton, which is then saturated with phenol solution. The cotton wisp should be held against the inside mouth of the phenol bottle to drain the excess phenol to prevent dripping. The phenol-soaked wisp is then applied to the matrix and vigorously rubbed into the treatment area for 30 seconds. One to two subsequent phenol applications are made in a similar fashion. The tissue will denature quickly and turn white or gray. The area is then irrigated with 30 to 50 mL of isopropyl alcohol and the tourniquet removed. The tourniquet should never be left in place for longer than 10 to 15 minutes.

Petrolatum or an antibiotic ointment is placed on the nail bed, the site covered with a nonadherent dressing (Telfa), and then the entire digit is wrapped with 1- or 2-inch roller gauze (Conform). The wrapping should be secure but not so tight as to be uncomfortable. Dressings wrapped too tightly may increase postoperative pain.

The patient is then advised to go home and elevate the affected foot or hand for 12 to 24 hours. Adequate elevation requires the limb be held above the level of the heart. Ice packs applied to the dorsal foot in the case of toenails or dorsal hand or wrist for fingernails seems to diminish pain and slow the clearing of anesthesia. Acetaminophen, ibuprofen, codeine or hydrocodone are appropriate analgesics when used in combination with, but not as a substitute for, elevation. Most pain occurs in the first 24 to 48 hours and the majority of patients can return to normal activities while wearing an open-toed shoe after 48 hours. Persistent pain or increasing pain after two days suggests an infection or chemical cellulitis. Infections should be cultured and treated with antistaphylococcal antibiotics; chemical cellulitis is treated with elevation, ice, and nonsteroidal antiinflammatory drugs.

Wound Care: Gauze coverings should be used postmatricectomy for one week, then adhesive bandages should be used for an additional two to three weeks.

A chemical cellulitis can occur secondary to the denaturing of tissue by phenol. Although some degree of chemical cellulitis occurs in many cases, it usually is not enough to warrant a visit to the physician. Important chemical cellulitis is recognized when the swelling not only involves the digit but the entire foot or hand or extends proximal to the foot or hand. Associated erythema and pain are variable. Most cases can be managed with continued elevation of the foot or hand to above the level of the heart, alternating cold and warm compresses and nonsteroidal antiinflammatory drugs.

Occasionally, chemical matricectomy does not completely prevent nail plate regrowth. When the regrown nail is a small spicule, it can be grasped with a hemostat and pulled out, a procedure that is associated with little discomfort. If a portion of the nail or the entire nail regrows, consider repeating the procedure, performing another ablative procedure, or referral.

Complications: Pain is the most common complication following nail surgery and is more likely to occur when infection is present before the procedure. Permanent procedures should be avoided in the presence of infection, and infection should be treated prior to operating whenever possible.

Contact Surgeon if pain worsens over 24 hours, increased redness in the area, a red streak develops, pus is present, fever develops.

In the first few postoperative days, bacterial infection, usually with Staphylococcus aureus, is most likely, but after one week, infections with Candida, which tend to remain localized, are increasingly prevalent. Candidal infections usually can be treated by discontinuing the antibiotic ointment and applying a topical antifungal agent. Do not use the combination of clotrimazole and betamethasone cream, because the potent steroid may exacerbate the fungal infection and retard healing.


Example Phenol Ablation Images (Click Images For Larger View)
Infected Ingrown Toenail Prior To Procedure

Infected Ingrown Toenail During Phenol Application

Pain & Infection Medications

Here's a quick summary of the medications I was prescribed and those I bought over-the-counter. Prescribed pain medication wasn't necessary for my single big toe removal, but I don't know how I would have functioned without prescribed pain medication for this multiple nail phenol ablation procedure.

Pain Medications
Percocet (oxycodone/acetaminophen) 7.5/325mg: prescribed, very helpful for pain but made working/studying difficult, used mostly at night or when planning on doing lots of walking.

Tylenol (acetaminophen) 500mg: over-the-counter generic, double dose (1000mg) provided good pain coverage during the day, max dose is 3000mg/day and the Percocet contains acetaminophen so you have to keep track.

Aleve (naproxen) 220mg: over-the-counter generic, double dose (440mg) was good for pain and great for inflammation, only used every other day because it was rough on my stomach.

Infection Medications
Silvadene (silver sulfadiazine) 1% 50g: prescribed, antibiotic wound ointment, less chance of chronic allergic reaction than with over-the-counter ointments (e.g. Neosporin), great stuff.

Keflex (cephalexin) 500mg: prescribed, 4x/day for 10 days given for wound infection after follow-up visit during second week, do not drink alcohol with this medication.

Other Medications
Phenergan (promethazine) 25mg: prescribed, anti-nausea medication to be taken with Percocet, enhances effect of Percocet as well.

Zantac (ranitidine) 75mg: over-the-counter generic, antacid with 1/2 day coverage that helped with naproxen stomach burn.

Benadryl (diphenhydramine) 25mg: over-the-counter genetic, sedating anti-histamine that helped with sleep instead of taking an additional Percocet.

Silver nitrate (AgNO3) stick: prescribed, used by the podiatrist to cauterize granulation tissue that is not healing well or quick enough.

Foot & Toe Bandaging

Bandaging Information (from podiatrist)
When you return home, regularly change your dressing/bandage for a number of days to make sure the wounds heal properly. It is important to keep the wounds covered until they are completely healed.
When your wound is covered and kept moist:
* It heals more quickly. Dressings/bandages that absorb your wound's fluids and maintain a natural moisture balance are ideal for healing.
* It decreases the change of scarring. Keeping your wound covered with a dressing/bandage can prevent a scab from forming and minimize the chances of scarring.
* It reduces the chance of infection. Dressings/bandages that are applied properly and changed as directed can help prevent exposure to water, dirt, and germs.
* It lessens the chance of re-injury. Dressings/bandages provide extra cushioning for added comfort and protection from re-injury.

Bandaging Supplies To Get
* 2x2 Gauze dressing and/or 3x3 Gauze dressings (generic brand).
* Box of 3/4" fabric or plastic adhesive bandages (generic Band-Aids).
* Paper towels to help with drainage during bandaging.
* Scissors to cut 3x3 Gauze into smaller pieces.
* Cotton swabs (generic Q-Tips) to help apply wound ointment.
* Cotton facial pads (e.g. Swisspers) to help separate toes.

Foot & Toe Bandaging Images (Click Images For Larger View)
Bandaging Supplies: Cotton swabs and wound ointment to apply to each toe before bandaging, 3x3 Gauze cut into 4 pieces (for each of the small toes), 2x2 Gauze for large toe, and fabric/plastic adhesive bandages to hold Gauze onto each toe.

Bandaging Completed: adhesive bandages hold Gauze pieces onto each toe, adhesive bandages wrapped around the back of the toe for large toe.

Moist Without Bandages + Ointment + Toes Separated: Cotton facial pads cut into 1/2 and 1/4 pieces, 1/2 pieces next to big toe, 1/4 pieces between smaller toes, pads folded length-wise then width-wise before placing between toes, make sure to keep wound moist if using this technique.

Surgical Shoes For Easier/Pain-Free Walking: Much easier to walk with than sandals or closed-toe shoes, provided at the surgical center as part of my procedure.

Comfortable Work Shoes

I have been very impressed with Dansko Professional Stapled Clogs. They are the most comfortable work shoes I've worn, comparable to running shoes. They look good enough for hospital work and clean easily, unlike when unmentionable liquids spill onto the mesh of running shoes. The biggest advantage of these shoes I've seen is that they actually breath, so my feet aren't sweaty after a 16hr shift.
Site - Dansko Shoes

The APMA Seal of Acceptance is granted to footwear, insoles, hosiery, materials, and equipment that allow for normal foot function and promote quality foot health. Site - APMA Seal of Acceptance

APMA accepted work shoes in 2010 are: Black Diamond Boots, Crocs Work Shoes, Dansko LLC, Footwear Industries Pty Ltd, HYTEST Safety Footwear, Nunn Bush, Rockport Works Collection, Sanita Clogs Inc, Timberland PRO.