Sir
We read with interest the article 'Conservative treatment of ingrowing toenails' by Reijnen and Cons (Br J Surg 1989; 76: 955-7). We acknowledge that a period of conservative treatment should be considered before surgical intervention; yet is it necessary for patients to endure such prolonged suffering for very little reward?
The absence of an alternative treatment group, such as simple nail edge packing or gutter insertion and the heterogeneous nature of the patient population combine to make this a poorly designed study. Eleven doctors undertook conservative treatment on only an average of I 1 nails but each individual's performance is not specified. The authors claim that their treatment is 'time consuming' but fail to report how long each primary treatment took. As patients were not reviewed independently, an unbiased, objective assessment cannot be made. The results of conservative management in the 30 patients who had previously undergone toenail surgery, and therefore demonstrated resistance to previous treatments, have been omitted.
The 'conservative' technique in itself appears to border on the barbaric. Analgesia requirements and the amount of pain suffered by each patient during this procedure are not stated. We suspect that lifting embedded nail edges out of the nail fold and filling the central portion of an ingrowing nail would be extremely distressing for the majority of patients if no analgesia was administered. Furthermore, 31 nails (26 per cent) ruptured as a result of filing. This morbidity is excessive and unacceptable.
Nail edge excision and phenolization under digital block anaesthesia in our experience can be completed in 15min and has a recurrence rate of i 1 0 per cent at one-year review'. The cosmetic results are satisfactory and the treatment is not attended by the complication of nail rupture.
Reijnen and Goris' proposed technique has not been shown to be superior to conventional methods of conservative treatment and cannot be justified in ingrowing toenail management.