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.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

32APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iSurgical treatments for ingrowing toenails (Review)


[Intervention Review]

Surgical treatments for ingrowing toenails

Catherine Rounding1 , Sally Bloomfield2

1Institute of Health Sciences, National Perinatal Epidemiological Unit, Oxford, UK. 2Gabatta clinic, Gabalfa, Cardiff, UK

Contact address: Catherine Rounding, Institute of Health Sciences, National Perinatal Epidemiological Unit, Old Road, Headington,

Oxford, OX3 7LG, UK. [email protected].

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.


A B S T R A C T

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).

1Surgical treatments for ingrowing toenails (Review)


mailto:[email protected]

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.

P L A I N L A N G U A G E S U M M A R Y

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.

B A C K G R O U N D

Description of the condition

Onychocryptosis or ingrowing toenails is a common condition

with an estimated 10,000 new cases presenting in the UK each

year (Sykes 1986) usually affects the big toe but may also affect the

lesser toes (DeLauro 1995). The condition occurs when the nail

plate punctures or traumatises the skin at the side of the nail, giving

rise to pain, inflammation and sometimes infection. When the

nail punctures the skin, attempts at healing lead to the formation

of highly vascular tissue called granulation tissue. This continues

to be produced until the splinter of nail is removed.

The nail may push laterally or distally against the flesh of the toe

for a variety of reasons but if the footwear is a poor fit it will always

worsen the problem. People born with a nail plate which is very

curved from side to side are predisposed to ingrowing toenails.

Ingrowing toenails are most frequently seen in adolescents and

young adults but it is a common problem in all age groups. In

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

of reduced ability to care for the nails because of reduced mobility

or impaired vision. As part of the natural ageing process the toe-

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 intervention

For most cases, conservative treatment in the form of basic foot care

and footwear advice is probably adequate to relieve the symptoms.

When the problem is recurrent, health professionals often view

surgery as the best treatment option to permanently remove either

the whole nail or just the troublesome portion of the nail.

Surgical procedures are carried out routinely under a local anaes-

thetic by general practitioners (GPs), podiatric surgeons, podia-

trists, general surgeons and orthopaedic surgeons. Podiatrists al-

most always carry out nail avulsion with phenolisation. The phe-

nol is applied to nail matrix after the troublesome nail section

has been removed. Its caustic action destroys the nail matrix and

should prevent regrowth. Other professions can choose the more

invasive methods of surgical excision of the nail matrix. Use of cry-

oprobe and use of negative galvanic current are less usual methods

of nail bed ablation which have been used by practitioners

Why it is important to do this review

Despite various trials, there is disagreement on which procedures

produce the most consistent results. Variation in practice (Sykes



1986) and patient satisfaction (Laxton 1995) is still wide. A survey

of current practice of GPs in Oxfordshire, UK (Milwain 1998,

unpublished) further demonstrates this variation in practice. In

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

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

technique of cryotherapy. In an audit by Laxton, podiatrists using

phenolisation achieved the lowest rates of regrowth (13%) and

the highest rates of patient satisfaction when compared to GPs,

general and orthopaedic surgeons. The rates of regrowth for GPs

were 34% and 50% for general surgeons. Not surprisingly, levels

of patient satisfaction reflected this.

This systematic review will draw together evidence on the different

options for surgical treatment of ingrowing toenails with the aim

of enabling practitioners and consumers to make informed choices

on the most effective way to cure this very common problem.

O B J E C T I V E S

To evaluate the effectiveness of methods of the surgical treatment

of ingrowing toenails. The object of performing surgery on an in-

growing toenail is to prevent its recurrence and so cure the prob-

lem. Therefore the primary outcome measure is the degree of re-

growth.

M E T H O D S

Criteria for considering studies for this review

Types of studies

Any randomised (or quasi-randomised) clinical trial which com-

pares one form of surgery to another or other treatments. The

studies must have a follow-up period of at least six months so that

it is possible to evaluate whether the problem has been cured.

Types of participants

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

vascular disease were to be included, making the assumption that

a patient would only be considered if they have been assessed and

found to be a suitable candidate for surgery.

Types of interventions

Any procedure which aims to permanently remove all or part of a

nail due to its impact on the soft tissues.

Types of outcome measures

Primary outcomes

• Regrowth/relief of symptoms

Secondary outcomes

• Healing time

• Infection

• Post-operative pain - both duration and intensity of pain

• Patient satisfaction

Search methods for identification of studies

Electronic searches

Section 5 of the Cochrane Collaboration Handbook (1997) was

used as a guide to identify the optimum number of relevant RCTs.

An electronic search of CENTRAL was undertaken, followed by

searches of other databases (MEDLINE post 1993, EMBASE,

CINAHL) which have not yet had their RCTs incorporated into

CENTRAL

Electronic searching of Cochrane Skin Group’s specialist register

of trials (please see Appendix 1 for the search terms used).

Searching other resources

Schools of Podiatry were contacted to request dissertation bibli-

ographies and information on unpublished studies.

Reference lists of all papers identified by electronic searching were

searched.

Contact with manufacturers of cryotherapy, radiowave and elec-

trosurgical equipment to identify published or unpublished stud-

ies.

Data collection and analysis

Selection of studies

Selecting trials for inclusion:



Two independent authors selected all randomised controlled trials

which met the inclusion criteria. (Disagreements were resolved

through discussion). Quasi-randomised trials, where the allocation

to procedures was not adequately concealed (eg allocation by date

of birth) were also be included but a sensitivity analysis was carried

out to see if excluding the one trial using this type of allocation

would significantly alter the results.

Data extraction and management

Data extraction was carried out independently by the two authors

using a pre-derived data extraction form. Data was entered into

RevMan.

Assessment of risk of bias in included studies

Assessment of methodological quality

Two authors critically appraised the papers independently to a

pre-defined standard. There was little disagreement, and this was

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-

treat analysis, baseline comparability and completeness of follow-

up.

Assessment of heterogeneity

Heterogeneity between comparable trials was assessed using clini-

cal judgement and tested using the chi-square test available in the

RevMan software. If significant heterogeneity was found statisti-

cally, sensitivity analysis with respect to patient characteristics, for

example, those with diabetes, was to be performed to identify the

source. If the heterogeneity could still not be explained then the

random effects model will be used. Where studies are found to be

suitably homogenous, meta-analysis was performed.

Data synthesis

The categorical outcomes were analysed as odds ratios with 95%

confidence intervals, with continuous outcomes such as pain or

healing time as effect sizes.

R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of excluded

studies; Characteristics of ongoing studies.

Results of the search

Twenty-one studies were identified for possible inclusion in the re-

view. From these, nine fitted the inclusion criteria (Anderson 1990;

Andrew 1979; Greig 1991a; Issa 1988; Leahy 1990; Morkane

1984; Tait 1987; van der Ham 1990; Varma 1983). Two stud-

ies are awaiting further information/data from the authors (Sykes

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-

fessionals (surgeons and chiropodists) performing phenolic abla-

tion and therefore does not fit the inclusion criteria. However, the

authors initially set out to compare phenolisation against surgi-

cal avulsion, but poor results led to the surgical avulsion arm of

the trial being discontinued. If additional data was available from

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

enough to be able to make a judgement as to whether the study

was prospective or whether allocation/concealment was adequate.

The study could not be definitely excluded until this can be clari-

fied.

Included studies

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

phenol with an excisional procedure (involving surgical removal of

the nail matrix) and either compared it against phenolisation with

avulsion alone or excisional surgery alone. Some trialists were spe-

cific in their surgical methods, naming the actual procedure used

eg Winograd, while others were less so, using the broader term of

’wedge excision’. One study (Greig 1991a) compared the use of

partial nail avulsion and phenolisation with simple partial or total

nail avulsion alone. It was debatable whether this study fitted the

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.

None excluded participants by their age or medical history. Three

studies (Greig 1991a; Morkane 1984; van der Ham 1990) ex-

cluded participants who had had previous toenail surgery and one

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

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

1988; Morkane 1984). Post-operative infection was recorded in

four trials (Anderson 1990; Greig 1991a; Leahy 1990; Tait 1987).

Pain intensity and/or duration was reported in five trials (Issa 1988;



Leahy 1990; Morkane 1984; Tait 1987; van der Ham 1990 but

usable data were not supplied. Similarly healing time was reported

in four trials (Andrew 1979; Tait 1987; van der Ham 1990; Varma

1983) but not with usable data.

Excluded studies

Nine studies were excluded from the review. Four studies had a

follow-up period of less than six months (Beaton 1990; Burssens

1987; Goslin 1992; Holt 1987), two did not compare interven-

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

excluded study (Wallace 1979b) did not fit the inclusion criteria in

the sense that one of the interventions did not aim to permanently

remove all or part of a nail.

Risk of bias in included studies

Allocation

All the included trials were described as randomised although three

did not state the method used. Of the remaining trials, three allo-

cated by sealed envelopes (Leahy 1990; van der Ham 1990; Varma

1983), one by random numbers (Issa 1988), one by hospital num-

ber (Andrew 1979) and one by date of birth (Tait 1987).

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-

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

months or more. The other trials did not state who they used to

follow-up the procedures.

Incomplete outcome data

Follow-up was very complete with all studies reporting the number

of participants lost to follow-up. Seven of the nine included studies

had a loss to follow up of 3% or less with the remaining two

having loss to follow-up of 13% (Tait 1987) and 6% (Varma 1983)

respectively.

Effects of interventions

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,

with OR = 0.07 (95% CI 0.04 to 0.12; Analysis 4.1). 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). Fewer

participants who had had phenolisation were dissatisfied, despite

the increased incidence of post-operative infection (OR = 0.19;

95% CI 0.11 to 0.34; Analysis 4.7). It is important to bear in

mind that these results are drawn from only one study of 168

participants (Greig 1991a).

Avulsion with phenol versus surgical excision

Phenolisation combined with simple avulsion of a nail is more ef-

fective than the use of more invasive excisional surgical procedures

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

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

out excluding the trials considered to have inadequate allocation/

concealment (Andrew 1979; Tait 1987) the OR was 0.47 (0.23

to 0.95); the results were still statistically significant.

There were too few data in the comparisons between phenol com-

bined with surgical excision and phenol (used alone), and phe-

nol combined with surgical excision and surgical excision alone to

draw any clear conclusions.

D I S C U S S I O N

Summary of main results

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

MEDLINE. Although schools of Podiatry were contacted, and

their response was good, no studies meeting the inclusion criteria

were identified. Equally, the manufacturers of cryotherapy, radio-

therapy and electrosurgical equipment responded well but no suit-

able studies were identified from this avenue. Two ongoing studies

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

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

where infection rates were significantly lower in the group which



had simple avulsion without the addition of phenol. This outcome

was to be expected as although phenol is antiseptic it is also highly

caustic, causing more tissue damage and so more opportunity for

infection. It was interesting to note, however, that in the discussion

section of six of the nine trials the trialists felt that it was generally

preferable to use phenol, two felt it made no difference and one

did not comment.

In the trials where patient satisfaction was recorded, methods of

assessing this were not described and any data should be regarded

with caution. Three trials were excluded because of a follow-up of

less than six months. Although this meant that data were excluded,

it was felt that this was justified, as symptomatic recurrence could

not be measured accurately in a time period of less than six months.

Skill of the operator in performing the procedures is an important

consideration and was not taken into account by any of the trials.

All the trials were undertaken by general surgeons in a hospital

outpatient setting. This does not reflect the large number of pro-

cedures performed by other professionals, particularly those in the

community, for example general practitioners and podiatrists.

No trial attempted to measure cost effectiveness of each procedure.

This could be an important consideration if all other factors are

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,

diabetes or mild ischaemia

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

From the results of one study, the addition of phenol when sim-

ple nail avulsion is performed decreases symptomatic recurrence,

but at the cost of increased post-operative infection. While use of

phenol will be most appropriate and beneficial for the majority of

people, risks and benefits should be discussed with each patient.

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. It should however be borne in

mind that one trial (van der Ham 1990) had a large influence on

the results.

Implications for research

Further well designed trials are needed to confirm that the use of

phenol on the nail matrix is preferable to nail matrix surgical ex-

cision. New trials should also examine short-term outcomes such

as healing time and pain as well as the primary outcome of recur-

rence.

A C K N O W L E D G E M E N T S

Philip Alderson, UK Cochrane Centre

Iain Chalmers, UK Cochrane Centre

Mark Lodge, Cochrane Cancer Network

R E F E R E N C E S

References to studies included in this review

Anderson 1990 {published data only}

Anderson JH, Greig JD, Ireland AJ, Anderson JR. Randomized,

prospective study of nail bed ablation for recurrent ingrowing

toenails. Journal of the Royal College of Surgeons of Edinburgh 1990;

35:240–2.

Andrew 1979 {published data only}

Andrew T, Wallace WA. Nail bed ablation - excise or cauterise?A

controlled study. British Medical Journal 1979;1:1539.

Sykes PA, Kerr R. Treatment of ingrowing toenails by surgeons and

chiropodists. Chiropodist 1988;43:224.



Greig 1991a {published data only}

Grieg JD, Anderson JH, Ireland AJ, Anderson JR. The surgical

treatment of ingrowing toenails (Study 1). Journal of Bone and Joint

Surgery. British Volume 1991;73:131–3.

Issa 1988 {published data only}

Issa MM, Tanner WA. Approach to ingrowing toenails: the wedge

resection/segmental phenolization combination treatment. British

Journal of Surgery 1988;75:181–3.

Leahy 1990 {published data only}

Leahy AL, Timon CI, Craig A, Stephens RB. Ingrowing toenails:

improving treatment. Surgery 1990;107:566–7.

Morkane 1984 {published data only}

Morkane AJ, Robertson RW, Inglis GS. Segmental phenolization of

ingrowing toenails: a randomized controlled study. British Journal

of Surgery 1984;71:526–7.

Tait 1987 {published data only}

Tait GR, Tuck JS. Surgical or phenol ablation of the nail bed for

ingrowing toenails: a randomised controlled trial [published

erratum appears in J R Coll Surg Edinb 1988 Apr;33(2):109].

Journal of the Royal College of Surgeons of Edinburgh 1987;32:

358–60.



van der Ham 1990 {published data only}

van der Ham AC, Hackeng CA, Yo TI. The treatment of ingrowing

toenails. A randomised comparison of wedge excision and phenol

cauterisation. Journal of Bone and Joint Surgery. British Volume

1990;72:507–9.

Varma 1983 {published data only}

Varma JS, Kinninmonth AW, Hamer Hodges DW. Surgical wedge

excision versus phenol wedge cauterisation for ingrowing toenail. A

controlled study. Journal of the Royal College of Surgeons of

Edinburgh 1983;28:331–2.

References to studies excluded from this review

Beaton 1990 {published data only}

Beaton DF, Kriss SM, Blacklay PF, Wood RF. Ingrowing toenails: a

patient evaulation of phenolisation versus wedge excision.

Chiropodist 1990;45:62–4.

Burssens 1987 {published data only}

Burssens P, Vereecken L, Van Loon C. [A comparative study of 2

treatment methods for onychocryptosis (ingrown toenail)]. Acta

Chirurgica Belgica 1987;87:294–7.

Fulton 1994 {published data only}

Fulton GJ, O’Donohoe MK, Reynolds JV, Keane FB, Tanner WA.

Wedge resection alone or combined with segmental phenolization

for the treatment of ingrowing toenail. British Journal of Surgery

1994;81(7):1074–5.

Gem 1990 {published data only}

Gem MA, Sykes PA. Ingrowing toenails: studies of segmental

chemical ablation. British Journal of Clinical Practice 1990;44:

562–3.

Goslin 1992 {published data only}

Goslin RW. A comparison of the dilution and non-dilution of penol

with alcohol following nail avulsions. The Foot 1992;2:225–8.

Greig 1991b {published data only}

Greig JD, Anderson JH, Ireland AJ, Anderson JR. The surgical

treatment of ingrowing toenails [Study 2]. Journal of Bone and Joint

Surgery 1991;73-B:131–3.

Holt 1987 {published data only}

Holt S, Tiwari I, Howell G. Phenolisation as an adjunct to Zadik’s

procedure for ingrowing toenail and onychogryphosis. Journal of

the Royal College of Surgeons of Edinburgh 1987;32:228–9.

Sykes 1988a {published data only}



Wallace 1979b {published data only}

Wallace WA, Milne DD, Andrew T. Gutter treatment for ingrowing

toenails (study 2). British Medical Journal 1979;2:168–71.

References to studies awaiting assessment

Sykes 1988b {published data only}


chiropodists (study 2). Chiropodist 1988;43:224.

Sykes 1988c {published data only}


chiropodists (study 3). Chiropodist 1988;43:224.

Zaborszky 1997 {published data only}

Zaborszky Z, Fekete L, Tauzin F, Orgovan G. Treatment of

ingrowing toenail with segmental chemical ablation. Acta

Chirurgica Hungarica 1997;36(1-4):398–400.

References to ongoing studies

Crawford 2001 {published and unpublished data}

An evaluation of ingrowing toe nail surgery in primary care.

Ongoing study 01/01/2000.

Thomson 2001 {published and unpublished data}

A clinical and economic evaluation of toe nail surgery performed by

podiatrists in the community and surgeons in the hospital setting: a

RCT. Ongoing study 01/06/99.

Additional references

Bremmer 1976

Bremmer DN, McCormick JC, Price MH, Hunter E. Ingrown

toenail: an evaluation of current treatment methods. Chiropodist

1976;31:330–5.

DeLauro 1995

DeLauro T. Onychocryptosis. Clinics in Podiatric Medicine and

Surgery 1995;12(2):201–13.

Laxton 1995

Laxton C. Clinical audit of forefoot surgery performed by registered

medical practitioners and podiatrists. Journal of Public Health

Medicine 1995;17(3):311–7.

Milwain 1998

Milwain. Ingrowing toenail surgery - a survey of current practice

amongst GPs. 1998.

Sykes 1986

Sykes PA. Ingrowing toenails: Time for critical appraisal?. Journal

of the Royal College of Surgeons of Edinburgh 1986;31(5):300–4.∗ Indicates the major publication for the study



C H A R A C T E R I S T I C S O F S T U D I E S

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



D A T A A N D A N A L Y S E S

Comparison 1. PHENOL AND AVULSION vs SURGICAL PROCEDURES

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Symptomatic recurrence at 6

months or more

5 585 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.44 [0.24, 0.80]

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

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

procedure

0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable



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


studies

No. of



months or more


1.1 Zad*k’s and phenol vs

zad*k’s


1.2 Winograd and phenol vs

winograd


1.3 Wedge/segmental excision

and phenol vs wedge/segmental

excision


2 Asymptomatic recurrence at at

least 6 months



zad*k’s



winograd




excision




zad*k’s



winograd




excision




zad*k’s

Other data No numeric data


winograd




excision




zad*k’s



winograd




excision


6 Healing time 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable


zad*k’s

0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable




winograd




excision



procedure



zad*k’s



winograd




excision




zad*k’s



winograd




excision


Comparison 3. PHENOL AND AVULSION vs PHENOL AND SURGERY


studies

No. of



months or more


1.1 Phenol vs Zad*k’s and

phenol


1.2 Phenol vs Winograd and

phenol


1.3 Phenol vs wedge/

segmental excision and phenol



least 6 months



phenol



phenol







phenol



phenol









phenol



phenol







phenol



phenol





6 Healing time 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable


phenol



phenol






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


studies

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




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


A P P E N D I C E S

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

F E E D B A C K

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



W H A T ’ S N E W

Last assessed as up-to-date: 27 October 2002.

12 June 2008 Amended Converted to new review format.

H I S T O R Y

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

D E C L A R A T I O N S O F I N T E R E S T

None known

N O T E S

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.



I N D E X T E R M SMedical 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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Transcript of Cochrane - Phenol