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Hi all,

6/52 ago I performed a partial nail avulsion on a 15 yo male patient with a history of cryptosis with localised infection and associated hypergranulation tissue. The procedure went smoothly, I saw him later the same week for re-dress with Allevyn NA and Tubigauze which he was to replicate every 4-5/7 for three weeks and bathe the site in salt water for 4-5 mins between dresses. The site was healing well and after 3/52 we switched to a simple dry dressing (Cutiplast Sterile).

Since switching to the Cutiplast the site has continued to heal well with the exception of the area of what was hypergranulation tissue. It appears to have become quite fibrous and epithelial in nature, it also remains well vascularized. During the phenolisation at the time of the PNA I applied some to the hypergran and have been debriding the associated HK and applying silver nitrate since. The mass is smaller in size than at the initial PNA but improvement appears to have stalled in the last 2/52.

Does anyone have any suggestions as to how I may proceed? As I say it is still vascular and debridement with a blade is not really an option I wouldn't think. I also don't think that it would be a great outcome from the patient's point of view for an epithelial mass to remain in the sulcus.

Any imput or suggestions would be greatly appreciated.

Leigh

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Hello Leigh,
Have to tried debriding back to the point where it bleeds, then apply your silver nitrate? I have used this technique on a neuropathic ulcer & it is healing beautifully. Also used it on a hypergranulating PNA site that settled after one treatment. I have also seen it used to treat an amputation site with massive hypergranulation, again it had to be debrided back to bleeding. Explain to your patient that it will bleed ( have the floor/ debris tray set up ready!), but not to panic.
Good luck,
Kara

Carry out a plastic lip procedure to remove the hypergranulation or it will become organised and leave a 'flap' of tissue over the nail edge.

Hope this helps

Bill Liggins

Forgive my ignorance bill but what is a plastic lip procedure?

Steve

A total 6-8/52 only represents two skin turn-overs... there's still time for slow healing to complete, if you are prepared to continue monitoring and the client willing to self-care.

However, as part of your differential diagnosis of the cause of ongoing hyper-gran tissue, perhaps the original irritation (nail edge) is still too close? I prefer to remove only the involuted side of the nail, leaving an appearance of a 'normal width' nail which is appreciated by the client. However, when extensive hyper-gran is already present, this width can iminge upon and continue to irritate the sulcus, hence its steadfast refusal to reduce to nothing... From experience, after several months of trying to resolve such tissue, I once simply had to re-operate on the edge of the nail (free of charge) and reduce the width further, resulting in complete and ongoing resolution. From this, I learnt why some recommend removal of 'upto a third' of the nail width, to ensure a first-time healing - it sounds extreme, but now I understand better why some present with such narrow post-operative nails.

I tend to agree with gdenbyUK.
I've had this happen a couple of times over the years, and resolved it by re-doing the procedure and removing a little more nail.

you need to do abiopsy of this tissue i had one once which on biopsy was amalignant melanoma if its not usual get it checked out

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drive it like you stole it

So with the hypergran tissue you are stalled in the inflammatory phase of healing. You need to address the possible causes for this. Think possibly inadequate dressing or possibly critical colonization of the wound. Maybe try Silver or Iodosorb to reduce bioburden. Just my 2 cents

This has happened a couple of times to my patients. In one case I re-operated removing more nail and the other I anaesthetised and used a tourniquet and removed the hypergran with a 15 scalpel blade.

I now routinely remove hypergran with a scalpel when performing a PNA and apply a little phenol to the sulcus as well as the nail matrix. These toes heal well and give a more asthetically acceptable result than removing large sections of nail. I always feel it is a shame to see nails that are no more than runway strips when over zealous removal of both sides has been performed.

One other thought is that if the ingrowing nail has been present for a long time then the over-lapping hypergran becomes more organised and resembles normal skin. This I saw on a young lad with a needle phobia who had put up with his ingrowing nail for 10 years! His girlfriend gave him the ultimatum, it's me or the nail who goes!

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Thanks all for your imput.

Kara47: What you recommended is what I've been trialling so far. I will most likely give it one more shot before discussing re-doing the PNA with the patient.

If the nitrate continues to have minimal impact I imagine I'll have no choice but to remove some more of the nail as some of you have suggested. Hopefully it doesn't come to this but at the end of the day it is probably for the best.

FishPod thanks also for the ddx of the melonoma. I shall certainly keep it in mind should things appear perculiar in some way.

I'm seeing the patient next week so I'll let you all know the verdict.
Thanks again for all your suggestions.

Leigh

Hi Steve

It's simply the removal of a longitudinal wedge of tissue from the nail fold.

All the best

Bill

Thanks again to all of you for your involvement, I've seen the patient twice since the original post.

The first time, now 8/52 since the PNA, the epitelial mass was still there. At this point I was convinced that the procedure would need to be re-done at some point. The patient wasn't keen so I once again debrided and applied Ag Nitrate. The difference being this time I was able to debride/remove pretty much the entire mass of epithelial tissue as, despite being highly vascular, it appeared to have no nerve supply what-so-ever. I also reduced the laterally border of the nail plate as aggressively as possible.

I saw him again today, now 10/52, and things are looking really good. None of the mass has returned and the border of the nail plate looked clear of any spikes.

I have decided to review him again in 2/52 as it has taken 10/52 to get this far and I'd hate for it to go pear-shaped now!

Leigh

Is he taking any medications for acne?

ToughSpiders,

not as far as I know, why do you ask?

Isotretinoin - Ingrowing toe nails

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