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Just wanted to ask your advice regarding the best dressing to put on after toe nail removal.
I have a bilateral toe nail removal next week. I dont get many toe nail removals and want to make sure I am giving my patient the best treatment and care as possible. (I will be using the EZ swab for the first time which I am looking forward to.) I assisted with nail surgery 3 months ago and they used gauze only.
Any advice would be appreciated. Thanks.

I dress with betadine liquid, apply a non stick dressing such as jelonet or bactigras, cover with melolin, non-woven gauze, conformable bandage and a couple pieces of hypafix. Cheers.

I use Melolin (non-adherent dressing), some sterile gauze swabs and tubegauze for the initial post-op dressing. Patients report minimal/no post-op pain and healing rates/rate of infection is the same as with other dressings (such as Bactigras + Melolin + TG).
Needs to be removed after 3 days and (after bathing affected nail bed in saline) should be replaced daily with Melolin or similar (Release & Telfa both being cheap alternatives), TG and a small piece of tape until the wound has scabbed over.

Bactigras, non adherent gauze and tube gauze - mefix/hypafix

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Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

Bactigras or bactigras sandwich, filled with kaltastat, if a real bleeder! Sterile gauze, tg and mefix.

Cheers,
Bel

__________________
I know, I know for sure
ding, dang, dong, dong, deng, deng, dong, dong, ding, dang.
.

As a rule I use bactigras directly on the wound then a Tricotex/Kaltostat sandwich then 3 or 4 layers of s/g tubeinette and mefix
Bloody marvellous - never has a strike through yet - always my priority for first 72 hrs

we use algisite and release covered with sterile gauze and tubegaze immediately post operatively. The patient is seen the following day and an iodine based dressing used with release/tubegause. As healing progresses, and levels of discharge decrease,the dressing is changed to a dry dressing.

i use bactigras, 3 layers of sterile gauze and melolin ever since working in nhs but trained using na ultra to allow drainage of site(i think cost an issue in nhs)

Betadine skin antiseptic application pre-op. Bactigras/equivalent chlorhexidine tulle gras dressing direct to exposed nailbed. Sterile gauze x2, #12 sterile tubular bandage, Mefix retention tape. Leave for 3/4 days. Inspect for any sign of infection. Redress as before with Bactigras. Change dressing at 3/4 day intervals after warm saline soak for 5 minutes - the patient can do this themselves. Review at 6 weeks. Good luck with the procedure.

Step 1: Non-adherent dressing on the wound site, for example vaseline impregnated gauze.

Step 2: 2x2 square sponges for pressure to decrease bleeding.

Step 3: wrap with 4x4 gauze folded length wise.

Step 4: 1 inch gauze roll wrap

Step 6: paper tape

start soaking next day.

I dont put any polysporin topical antibiotic, sometimes people have a localized reaction to this and then you cannot tell if its a reaction or an infection.

Good Luck

Bactigras, Kaltostat, Melolite, TG and Mefix. pt does daily salt water foot bath for 5mins and re dress with dry dressing.

Sam

Was taught to use Bactigras or similar impregnated gauze and then 2X2s on top for pressure. After attending a conference where this topic came up, there was a suggestion to try AmeriGel hydrogel, instead of Bactigras. I have tried this only a couple of times, but the results so far have been fantastic - with faster healing times, and little post-op pain.

I agree, once you have decided on the dressing of choice, salt baths are very helpful in reduced healing time

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Michael Weber

The most common thing about common sense is it´s not very common.

My location

when we were training we used to have the pt come every week for a re dress and they kept the dressing on all week. It used to take forever to heal, since qualifying and doing the salt water foot baths every day the healing time has reduced quite alot. prob by half

Sam

Cant remember the research that was done, but salt baths are out- patients just get toe wet in shower daily as normal and then apply dry dressing. Healing times are faster than when I used to keep the toe dry for a week and then use saline soaks, as I was trained to do.
Post op dressing is bactigras and sterile gauze, removed next day and patient dresses with melolin daily.

Cornmerchant

Stericlens sterile NaCl irrigation, Inadine (or Betadine), Gauze, Mepore and Tubegauze bound firmly. Kaltostat only for excessive haem.
Keeping the wound moist encourages faster healing time and reduces post-op and dressing change pain.
I also advocate NaCl footbath home treatments.
Patient education encourages compliance and improved outcomes.

Amerigel does work well, below are instructions copied from their website. I also used Neosporin and wet to dry saline dressings changed QD. The dressing keeps it moist and helps to absorb and remove the debri. The saline provides a hypertonic environment helping to draw out the exudate into the gauze. I do not like Betadine as it inhibits wound healing.

I also never used Phenol but rather NAOH as it can be neutralized with acetic acid. Patients have far less drainage and pain than using Phenol.

For quickest healing, I would not use any chemicals at all. I would do a Suppan procedure. I would excise the nail matrix with a #64 Blade (entire nail matrix or matrix from offending border) and apply one or two stitches. Minimal to no pain and no drainage and heals the fastest. I would apply Neoporin and a wet to dry saline dressing and see the patient in about 3 days for dressing change and remove the suture. Usually, neosporin and gauze is all that is needed for another week.

Steven

Instructions following Nail Surgery
using AmeriGel® Wound Dressing
Download printable PDF here.

General Information:
Stay off your feet as much as possible today. You may wear any shoe, sandal or open toe footwear that does not squeeze, constrict or put pressure on your toe(s.) Your toe(s) may remain numb for up to 6-10 hours after the procedure. Please contact our office if you have any questions or concerns.

Bleeding:
Slight bleeding, discoloration and drainage are normal.

Discomfort:
You can elevate your foot to help alleviate minor swelling, bleeding and discomfort. You may also take aspirin, Tylenol or other over-the-counter pain relievers as directed on the package. If pain or discomfort is not controlled adequately, then contact our office.

Removing the surgical bandage:
Starting the second day after surgery, carefully remove the dressing and shower or bathe as normal. If the gauze or bandage sticks to the area, dampen it with water or shower/bathe with the bandage in place. This will make it easier to remove with minimal or no discomfort.

DRESSING SHOULD BE CHANGED ONCE DAILY FOLLOWING BATHING.

CHANGING THE DRESSING:

Step 1: After showering or bathing, blot the surgical site (nail bed) dry and apply a liberal amount of AmeriGel® Wound Dressing. Stinging may occur and is normal

Step 2: Cut a suitable size piece of gauze to fit directly over the entire surgical area.

Step 3: Secure gauze in place with a band-aid. IMPORTANT: The band-aid should be applied around the toe resembling a ring. When dressing a toe, apply band-aid loosely.

Hi Steven,

The Suppan procedure was not one I have encountered previously. Had a Google.


JAPMA


A New Onychocryptosis Classification and Treatment Plan



Many thanks,

Mandy.

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:)
twirly

Mandy Brooks
Brooks Podiatry
S64 0DE

Suffering a fondness for odd things.

Thank you all so much. Your replies have been very informative.

Yvonne

I use bactigras or jelonet - kalt for bleeders melolin x 2.
Im curious about the sodium hydroxide...ive heard about it use in nail surgery but im even more curious about the acetic acid? In terms of sterility and effects on the wound bed.
If someone can enlighten me that would be great. If this is a suitable alternative to phenol id consider it.

Inadine impregnated desssing followed by melolin or mepore and to hold in position with tubegauze bandage. Follow up 2-3 days. If the area remains wet continue with inadine and melolin, if the wound is dry commence saline soaks and cover with a dry non adhesive dressing such as telfa or release
All the best

Hmmm....watch out for intolerance/allergy, there are a growing number of pts who cannot toleate inadine. I wouldn`t routinely use it, especially with so many peeps out there with undiagnosed thyroid disorders.

In 2001 the Journal of Community Nursing published an article on the use of iodine in wound care, and this included Inadine. This reported:

“These dressings are not advised for use in patients with thyroid disorders..”

Cheers,
Bel

__________________
I know, I know for sure
ding, dang, dong, dong, deng, deng, dong, dong, ding, dang.
.

sorry I ment a Betadine dressing

[quote=yvonneg;141561]
(I will be using the EZ swab for the first time which I am looking forward to.)

Hi Yvonne - is the EZ swab a method for application of Phenol?

For nail removals + phenolisation I wouldn't normally apply any antibacterial product because the phenol will have destroyed any bacteria on the woundbed. I just use any n/a foam dressing + a few layers of tubegauze, adding in some fibres of kaltostat if there is any post op bleeding.

I also advise pts to change the dressing after bathing . No need for salt water soaks unless it gets infected, in which case 2x daily.

Hope it goes well and there's no regrowth!

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Mo

Hi Mo,

Thanks for your reply. Yes, the EZ swab is the latest for applying phenol. It looks like a cotton bud where the bud end is in a small pot filled with phenol. You break the seal by pushing the bud down into the pot and let it absorb the phenol. I am not sure I liked it as it seemed slightly large to get in the corners. It was definitely more convenient though. Phenol is getting harder to source. Most pods here are using the EZ swab. I bought some from another pod as it only comes in a box of 30 for just under £80. Quite a big outlay.
I have seen my patient since her op and her healing is fantastic. So I hope all goes well and there is no regrowth.

EZ swabs are a rip off. They are only available from one company so that keeps the price artificially high. Liquid phenol is not hard to get, comes at a fraction of the cost and has a longer shelf life.

Cornmerchant

After a phenol matrixectomy dilute wound with copious amounts of alcohol dry and apply a small square of viscopaste with 2x2 gauze and wrap with coban for at least 4 days and then change dressing to amerigel silk gauze and coban until drainage stops, with instructions to allow toe to air dry if would becomes masserated.

dv1131
With respect, your dressings in the States are different to ours here.
As you may have seen from previous posts, there is not a clinical evidence base for usng alcohol flush post operatively- some use saline, some use nothing. It seems to come down to who you trained under!

Cornmerchant