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Hi all,

I have recently attended a Nail Surgery (partial nail avulsion with chemical cautery of nail matrix) update/workshop/continuing education session in which a technique of phenol application was described that I had not seen before. The phenol was drawn up into a syringe, and then with the use of a needle, several small drops of phenol were "deposited" directly into the lower nail bed and matrix area. I have now done several procedures using this technique and find it very useful, albeit that a very steady and delicate touch are needed to ensure phenol only is deposited exactly where it is intended to go as the gap you need to work in is very small!

After to talking to many podiatrists, it seems to me that there is no general concensus as to:
1. the exact amount of phenol is ideal for this procedure using this method?
2. the ideal duration in minutes to leave the phenol in place during an application?
3. the ideal number of applications?

Can anyone help me with any info on these points?

Much appreciated,
Adam.

Adam,

The standard I as taught was three one minute applications followed by a saline flush. I'm not sure there has been any research supporting this.

I know the concerns with using a syringe for application has been the possibility of the plunger sticking and then releasing quickly causing splashing and injury to the patient and the clinician.

Regards

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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!::

Hi Adam:

After a few thousand of these you stop timing!!!!

For partial P&As I normally use two applications per/ side unless there is some bleeding (which may dilute the phenol) in which case I'll use more. I apply the phenol for appox. 20 - 30 seconds. Last applicator saturated with alcohol. This works well for me.

As far as "how much" - I use a miniapplicator stick (looks like a wooden Q-tip with very little cotton on it) and just dip it in 88% phenol.

Steve

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DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

I was never happy using phenol from a bottle - accident waiting to happen! Tried Electrosurgical matrisectomy for a while but the re-growth rate was unacceptable. I now use the Phenol EZ swabs apply 2 swabs to the sulcus for 1 minute each - excellent safety, seem to heal quicker (noticed less phenol flare) and so far no regrowths - been using them for about 18 months now

regards

steve

Yes, I agree this would be something to avoid at all cost, however I personally haven't found this to really be a risk as the pressure inside the syringe somehow causes the phenol to very slowly drip out of the needle without the need to squeeze down on the plunger at all.

Regards,
Adam

Hi Steve,

Where do you get the Phenol EZ swabs from?

I've never heard of them- what's the concentration of Phenol in them?

Cheers,

Brad Randazzo

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My location

Thanks Steve. A few thousand? Well, so far I'm around the few hundred mark I would say.

I wish I could find those mini applicator sticks here in Australia!! The ones I used to use I had to make up with a plain applicator stick and cotton wool wound around the tip (cringe) which once put through the autoclave never held up very well and were always too bulky for my liking.... Maybe a local collegue will point me in the right direction as to where to get these mini applicators.

Regards,
Adam

If they are even available in Australia?? If they are, I would like to know as well.

Regards,
Adam

If you snap / cut a wooden applicator a sharp point should be obtained, with a little cotton wool round it and some vigorious rubbing action on the matix for approx 20 to 30 seconds, 2 or 3 times each side is enough to caurterise it well.

I always use a torniquet of some kind and if bloody after nail avulsion , dry with sterile gauze.

I dont think there is a "standard Time / number of applications.

Do not every use Silver Nitrate (as I have seen from some GP's) for cautery of the matrix / nail bed as it forms an ecshar which is very slow to heal.

In our practice we normally use phenol 2 x 30 seconds, 3 x 30 if infected and 2 x 60 (although I have never needed to use 2/ 60 since practicing)

It would be great to know about the phenol EZ swabs and where to get them if available as phenol is getting harder to source these days

The below article was the one we verified things off at uni although I cannot remember specifics as I have misplaced the full text

Jeffrey S. Boberg, M. Shane Frederiksen, and Francois M. Harton
Scientific Analysis of Phenol Nail Surgery
J Am Podiatr Med Assoc 2002 92: 575-579.

Abstract

Chemical matrixectomy using phenol is one of the most common surgical procedures for the permanent removal of toenails. The concentration of phenol solution and duration of its application have varied widely and have not been subjected to scientific study. The authors studied the histologic effects of phenol on the nail matrix and determined the optimal concentration of phenol and time the phenol solution needs to be in contact with the nail bed.

Just dip a small dermal currette into the solution and apply with that. I draw up the solution out of the bottle with an drawing up needle and syringe, and deposit into a small galley pot. About 0.3cc is enough to kill the nails of an entire tribe of pygmies.

More controlled "dose" and less splashing and scatter. No need to purchase any additional supplies in the long term.

LL

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Remember, it's just a foot.

I have attended clinical updates where this method was discouraged as it is possible to leave wisps of cotton wool in the wound

We can get the EZ swabs in the uk from a supplier called DLT - google them and they maybe be able to put you in touch with the manufacturer - I will check my supply for details when i get back to work later today.

Steve

I also use Phenol EZ swabs (and also get them from DLT). Each EZ swab contains liquified phenol, USP 89%

Ian

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My location

I have been using the EZ swabs for a couple of years now and also find that 2 ampoules, applied for approx 1min each, produces excellent results.

The first design of these were quite cumbersome and not great for lesser digits, but they have been improved since. Healing time seems to be reduced in comparison to liquid phenol applied from a bottle.

Cheers
Bel

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Belinda Longhurst
Winchester (UK) Podiatry



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

Hi all,

I agree that the EZ swabs are great. Only problem is the cost. DLT have the monopoly on the product so the cost is high. Currently 1 pack of 30 swabs is £79.95. Liquified phenol 500ml from different supplier £12.45.

Regards,

Mandy

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:)
twirly

Mandy Brooks
Brooks Podiatry
S64 0DE

Suffering a fondness for odd things.

Hi all
I was taught 3 x 1 minute application of 80% phenol. With experience I find I'm hardly ever rigidly sticking to 1 minute.
Working almost exclusively in NHS the EZ swabs can prove prohibitively expensive. We carry out in excess of 600 procedures per year. This is set to increase as we have successfully bid to take on those individuals that historically GPs were still sending to secondary care.
After attempting several different methods of applying phenol the technique we now most consistently use is with ultra micro pastettes.
These are used in research labs for example to deliver a single drop of blood onto an agar dish.
Our phenol is delivered from pharmacy in 20ml bottles with a dropper top.
We use the dropper to transfer a small quantity into a gallipot and then suck it up into the micro pastette.
The phenol can easily be delivered very close and accurately to the site of the removed nail / partial nail.
I saw them used in a research lab and immediately recognised their application in nail surgery.
We order them from a company called Alpha Laboratories and they are very cheap.
I'd be more than happy to send anyone some samples to try if you're interested.

Michael

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Michael Gates,
Podiatrist,
Inverness ,
Highlands
Scotland

Hi Michael, that sounds very inventive and very effective. Maybe you could post a picture of this micro pastette if you have the time.

Adam.

Thanks LL, that sounds like a very good technique. Just to clarify, are you saying that you essentially "fill" the scoop of the curette with phenol by dipping it and that is how you measure/control your dose? How small is your small curette? And do you also do 2 X 30 secs?

Thanks,
Adam

Correct. Surface tension keeps the liquid quite well within the scoop of the curette. I use 1 or 2mm diameter curettes.

Typically I will work in through the pocket for about 2mins, or about half a song on iTunes - redipping once or twice.

LL

__________________
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Remember, it's just a foot.

LOL.... very scientific

Hi Adam

hopefully if my technology works I should have sent 2 pictures with this message. I put the micro pastette alongside a blacks file so you can get an appreciation of it's size.
These pastettes come in various lengths of stem and we did try longer stems that could be inserted directly into the phenol bottle. As the stem gets longer, however the control as you approach the toe end is reduced. This is the size we settled on that everyone feels comfortable using.

Michael

Attached Images

	micro pastette.jpg (2.14 MB, 188 views)
	micro pastette (1).jpg (2.12 MB, 177 views)

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Michael Gates,
Podiatrist,
Inverness ,
Highlands
Scotland

Thanks, thats helpful.

Thank you Micheal,

I've added what I believe is Alpha labs' link: http://www.alphalabs.co.uk/product_C...8&country ID=

Looks to be a very good idea.

Mandy.

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:)
twirly

Mandy Brooks
Brooks Podiatry
S64 0DE

Suffering a fondness for odd things.

They reckoned colleagues:
I have great experience in the technique of Phenol.
After 27 years of use in thousands of procedures, I have not found complications to emphasize, if the application of the technique is correct.

The most common causes of these errors are:
• To separate more nail of the desirable thing, habitually by using an alicate to cut this nail. By capillarity the phenol will eliminate more nail than the predicted one.
• Damages in the nail to respect, by inconsiderate handlings. It causes the subsequent fall of the sheet, that can be eliminated permanently, or its deviation on the digital axis.
• To Apply the phenol under the skin, you recall that is a technique not incisional, to use prior scrapings can cause internal burns with periostitis, or cysts by inclusion.
• Burns of the surrounding skin, by protect it not adequate with vaseline
• Pain in the base of the phalanx by hematoma post anaesthesia.
• Time of insufficient exposition, origin of relapses and espículas.

The times of application are relative. They depend indisputably of the quality of the skin of the patient, of their type and of their race.
Just like the people do not tolerate likewise the solar exposition, with the phenol we will find that the blond or red northerners of hair and pink and fine skin need shorter times of exposition than the patients with skin gross and dark coming southern.
If we respect the integrity of the skin in our surgery, the own skin cauterized protects to the deep weavings of the caustic effect, despite that the times of application be more long.
This does improper the debate on times of application, despite excellent articles on the theme:

Scientific analysis of the surgery of the nail with Phenol. Jeffrey S Boberg, M Shane Frederiksen, Francois M. Harton (J Am Podiatr Med Assoc 92(10) : 575-579, 2002). (Podología Clínica Vol. 4 nº 2 March 2003, in Spanish)

In my experience, use applications with three different sprinklers in each channel, without intermediate washes.
They are used to being of a minute, depending on the idiosyncrasy of the patient.
Finally I neutralize with an abundant wash with alcohol, substitutable by saline solution to criterion of the professional.
To avoid accidents, to use ALWAYS safety goggles.
I send you photography of the sprinklers used.
To emphasize the finest, mounted one on wire, and special for surgery in children and for lateral in the smaller fingers.
I believe that for the Australian colleagues, can be an excuse to travel to Spain in its search.
Cordial greetings:

Jose Antonio Teatino
Professor of Surgery
The Academy of Ambulatory Foot & Ankle Surgery

Attached Images

Hisopos.jpg (971.0 KB, 119 views)

Thanks Jose, I always wanted to go to Spain.....

I always thought the purpose of the phenol was to denature the proteins of the cells of the tissue that we are setting out to kill. There is a colour change associated with that and when the colour change is present the job should be done. I have always thought that a little more contact time was better than a regrowth of the reason you are doing it in the first place. I use a dipped Blacks file to place a small amount of Phenol in the little hole I have created and rub it around a bit to ensure good contact, seems simple, low cost and effective. Don't really agree with using a fibrous applicator.
regards Phill Carter

About ten years ago a UK podiatrist was handed by his assistant a syringe he had requested and believed to contain local anaesthetic;in fact it contained liquefied phenol and he injected this into the proximal phalanges of his patient's great toes which required amputations later that day by a surgeon.This might exemplify a possible danger of having liquefied phenol to hand in a syringe during nail surgery as detailed elsewhere today.Another danger could be phenol splashes and the unknown toxic effects of the phenol dissolving the plastic barrel of the syringe.I use cotton buds dipped in liquefied phenol and applied for two minutes and washed out by a hand-rub based on alcohol.

Scarey thought, I am guessing legal action came about infallablejeff?

I use the same technique as pg phenol in the galley pot dipped blacks file and rubbed around for good contact, has been simple and effective for me however the dermal curette does sound like a good idea also.
I was taught in between the vicinity of 1-3 minutes application of phenol in blocks of 30sec depending on the presence of infection or if there is any blood in the area which needs longer application. Seems there is a bit of discretion for everyone on the consensus.

LL I have visions of you with the headphones in on the ipod moving and shaking whilst applying the phenol for half a song, as long as its not a full length version of something like november rain or metallicas one!

What about stairway to heaven?

Thankfully I can assure you the headphones aren't on, but I do take pleasure in torturing my younger patients with my obscure new wave 80s playlists running through the laptop in the procedure room...That's usually when the "young folk" pull out their own iPods and turn them up - or is that after I wave the needle and syringe in front of them? Either way, if the music is loud enough it distracts them, and keeps me from hearing their howls of anguish...

PS. Nothing like some AC/DC to take their mind off it..and most of the songs come in under 3m50secs...

LL

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Remember, it's just a foot.