A survey of the treatment and management of ingrown toenails by UK podiatrists: A cross‐sectional survey

Abstract Background Ingrown toenails are a common pathology. Although a range of conservative and surgical measures are widely used for this condition, little is known about their use in practice. This study explored current practice relating to the treatment or management of ingrown toenails by podiatrists in the UK. Methods A cross‐sectional online survey (Qualtrics, Provo, UT, USA) conducted between March to June 2020 was distributed to practicing podiatrists treating or managing ingrown toenails in the UK. Results A total of 396 practicing podiatrists responded (60.1% based in the private sector). The majority (88.6%) performed nail surgery most commonly (54.3%) less than five a month. Nearly all (95%) only performed nail avulsion with or without chemical matrixectomy, universally using phenol (97.2%). Application time and number of applications varied but was most commonly applied three times (61.5%) for a total of 3 minutes (75%). Aftercare varied considerably between public and private sectors, with public sectors offering fewer follow‐up appointments. Conclusions Although there is a variation in clinical practice throughout the treatment pathway, almost all respondents offered nail avulsion with phenol matrixectomy, whereas very few provided incisional nail surgery. This data provides the most comprehensive description of how UK podiatrists conduct nail surgery for onychocryptosis.

and III), a surgical approach is often recommended [5].Although there are multiple procedures and options for performing such surgery, they typically aim to remove the problematic part of the nail and destroy the nail matrix to avoid painful regrowth [4][5][6].
A recent systematic review and meta-analyses concluded that despite the high number of publications on nail surgery, very few conclusions could be drawn from the evidence due to the poor quality of research [7,8].Notably when studies were assessed using the Cochrane RoB 2.0 tool, all studies were graded as having an overall bias of either 'some concerns' or 'high risk'.With such a limited evidence base, there is little to guide clinician's practice.
Although in the UK, the Royal College of Podiatry offer clinical practice guidelines that are not prescriptive in nature and formally auditing against them may be challenging [5].An alternative approach for clinicians seeking to evaluate the quality of their service and seek improvements is benchmarking, which is increasingly used across many different sectors including healthcare [9,10].
Although there are numerous definitions of the term, and it can be seen as a structured methodology in quality improvement [11], at its heart, benchmarking is a process of peer comparison, which has been shown to detect and reduce unwarranted variation [10,12,13].
To enable such comparative benchmarking in nail surgery, it is first necessary to describe current practice, but we were unable to find any contemporary data describing UK practice.Therefore, we aimed to describe current practice relating to the treatment of ingrown toenails by podiatrists in the UK.

| Study design
A cross-sectional online survey was conducted between March 23, 2020 to June 4, 2020.Findings are reported in accordance with the Consensus-based checklist for Reporting of Survey Studies (CROSS) reporting guideline [14].

| Data collection methods
Survey questions were drafted by experienced clinicians and foot and ankle researchers with the aim of questions to explore clinical practice.The questionnaire was circulated to 12 podiatrists, of which 7 provided comments and piloted the questionnaire before changes were made and the final survey was circulated.The final survey comprised 54 questions; the first section collected questions about participants' practice, location and sector and highest level of qualification.The second section explored the number of ingrown toenails treated, use of classification systems, treatments offered and types of conservative treatments offered.The third section focussed on the surgical treatment of ingrown toenails including pre, peri and post procedural details, the latter focussing on aftercare, patient outcomes and audits (Supplementary File 1).

| Sample characteristics
Participants were UK based and required to be currently practicing podiatry treating and/or managing ingrown toenails, regardless of whether they worked in the public or private sector.Therefore, any participants not based in the UK or not working with ingrown toenails were excluded.

| Survey administration
We used a cross-sectional, self-administered, anonymous survey to elicit the details of clinical practice using the Qualtrics online survey platform (Qualtrics, Provo, UT, USA).It was circulated by email to all members of the Royal College of Podiatry and advertised on social media including Twitter, the UK Podiatry, UK Podiatry Business and Podiatry UK Facebook groups.Consent was implied by survey completion.

| Statistical analysis
All responses collected through Qualtrics were inspected and downloaded to Excel, coded and analyzed using descriptive statistics (frequencies and percentages).We made an a priori decision to present public and private sector data separately but not to conduct inferential statistics due to the large number of variables collected and the lack of existing data upon which to base hypotheses or sample size calculations.All returned surveys were included in the analysis regardless of the level of completion; therefore, the total number of responses for each response vary due to missing data.

| Participant and professional characteristics
Overall, there were 396 eligible respondents to the survey of whom 297 (75%) were based in England (Table 1).One hundred and twenty-two (30.8%) respondents were in practice for 0-10 years, and the majority described working primarily in the private sector (n = 238/396; 60.1%).Undergraduate degrees were the most common reported level of education (n = 265/396; 66.9%).

| Clinical characteristics
Almost 72% of respondents treated five or more ingrown toenails per month, although over 80% did not use a classification or grading system to quantify severity (n = 325/389; 83.5%) (Table 2).
For those who utilised a classification or grading system, more than three-quarters used their own system (n = 40/51; 78.4%).Figure 1 2 of 11 -JOURNAL OF FOOT AND ANKLE RESEARCH shows the type of treatments offered, the most common being nail cutting advice (94.1%), partial resection (93.8%) and footwear/hygiene advice (91.9%).It was notable that packing was offered less in the public sector than the private sector (52.7% vs. 66.8%),whereas nail avulsion with or without matrixectomy was more commonly offered in the public sector.Supplementary Figure S1 shows that bracing systems are not commonly used in the public or private sector.S1 and Supplementary Figure S2).Supplementary Table S2 illustrates the pre-surgical management of health conditions and medication.
Application time and number of applications varied, but most commonly was applied three times (n = 150/244; 61.5%) for a total of 3 minutes (n = 183/244; 75%) (Figure 4).Notably, Iodine (n = 70/ 155; 45.2%) was the most commonly used disinfectant in the private sector as opposed to Chlorhexidine (n = 59/115; 51.3%) in the public sector (Supplementary Figure S3).Primary, secondary and tertiary dressings applied can be found in Supplementary Table S3.
Products provided for aftercare varied, with private sectors providing more dressings, tubegauz (or equivalent), hypafix®/tape, saline solution and clinisept® than the public sector (Supplementary Table S1).

| Follow-up
Care pathways varied between private and public sectors, with public sectors offering fewer follow-up appointments following total and partial nail avulsion, and more commonly appointments were only offered if complications were present (Table 5).Healing time for both total and partial nail avulsion were similar, with both sectors estimating 4--9 and 4-6 weeks, respectively, and advising on saltwater bathing between dressing changes (63.5%).Interestingly, only half (n = 134; 51.5%) of the respondents evaluate the outcomes of nail surgery, slightly more common in the public sector than in the private sector (56.8% vs. 47.7%).These evaluations most often included patient satisfaction (92%), were completed within 1-6 months  (59.2%) and were most commonly undertaken via a telephone consultation in the public sector (44.1%) or via a follow-up appointment (60.6%) in the private sector.Lastly, more than half of the respondents (n = 75/125; 60%) informed that they did not or were unsure whether they used a professional standard/guideline to audit compliance (Supplementary Table S1).

| DISCUSSION
This study aimed to describe UK practice around nail surgery in order to enable clinicians to benchmark their service due to the lack of existing data.Our online survey achieved 396 eligible responses in a short time window.With 72% conducting five or more and 17.5% conducting over 21 procedures per month, we have confirmed how commonly UK podiatrists perform nail surgery.
Although numerous surgical procedures have been described to treat ingrown toenails, 95% of respondents only performed nail avulsion with or without chemical matrixectomy rather than incisional nail surgery.Of the incisional nail procedures respondents offered, Winograd (4.9%) was the most common, followed by Zadiks (3.7%).Similarly, phenol was almost universally used for chemical matrixectomy with 97.2% of respondents using it.With such a large proportion only providing one procedure or one chemical, it is perhaps surprising that a recent systematic review identified that the current evidence base does not demonstrate superiority of one procedure or chemical over others for outcomes of relief of symptoms, symptomatic regrowth, healing time, post-operative complications, pain or patient satisfaction [7,8].Similarly, with Royal College of Podiatry guidelines stating that surgical excision may be considered where healing capacity is reduced, and primary intention would be more suitable, it is clear that most podiatrists would need to refer patients to enable this [17].
Phenol is a volatile organic acid used to destroy tissue in the nail matrix and prevent the pathological nail from re-growing.Clinicians must determine how long to apply the phenol in order to maximise the likelihood of a successful procedure whilst minimising the chances of excessive, unnecessary tissue damage.Our data showed that practice in the application of phenol varied between respondents and sectors.Although Royal College of Podiatry guidelines suggest three, one-minute applications of phenol in a well perfused hallux and this was the most frequently reported application pattern, our data shows that a range of timings are used in practice, with many using two applications.It is also notable that a larger proportion of respondents working in the public sector reported typically using two applications when compared to the private sector.Although it is important to clarify that this variation is not precluded within the guidelines, it does perhaps reflect the lack of evidence to inform decision making on key elements of the procedure [5,7,8].
Matrixectomy is considered a definitive treatment as it is used to prevent nail regrowth, but in our survey 59.6% of respondents said they offered nail surgery without matrixectomy.That is nail surgery to remove part or all of the effected nail, but enable it to regrow.This approach is advocated in the literature for a broad spectrum of indications including: when there is a singular incidence of ingrown toenail with no underlying nail pathology; removal of fungal nail in preparation for treatment; and poor healing capacity [18].In addition to specific clinical indications for this procedure, there is also increasing awareness of the post-operative cosmetic appearance following nail surgery [19].Given the breadth of indications for nail avulsion without matrixectomy, it seems surprising that 40% do not offer this option and suggests that matrixectomy may be over-used in   The primary limitation of the data presented here is that they were collected in 2020 and it is possible that practice has changed since then, particularly in the delivery of chemical matrixectomy following a National Patient Safety Announcement on the use of bottled liquid phenol in 2021 [20].Following this, the Royal College of Podiatry amended their guidelines and now recommend that only UKCA labeled phenol application products should be used [17].
Whilst this is likely to change the technique used to apply phenol during matrixectomy, it is not clear whether this has led to a change in the chemical used to destroy the nail matrix.Despite this, there has not been any similar data presented on national practice of nail surgery in the interim and this remains the most recent UK data to enable benchmarking.
The survey was open between March and June 2020, and this coincides with the first wave of the COVID-19 pandemic in the UK, which may have affected response rates.During this period, podiatrists were instructed by the UK government to only provide urgent care, which affected many private podiatrists, and a number of NHS podiatrists were redeployed to other areas [21].Conversely, it is also possible that we would not have had such a large response to such a detailed questionnaire had we asked outside this window, as usual working patterns for a lot of podiatrists were altered during this time.

F I G U R E 2
Most common indication for performing nail surgery (n = 328; private n = 188, public n = 140)*.*Multiple answers possible.

6 of 11 -
JOURNAL OF FOOT AND ANKLE RESEARCH

a 9 .
6% (n = 26/270) of respondents did not complete this question.b Multiple answers possible.F I G U R E 4 Total application time (A) and number of chemical applications offered (B) (n = 244).
Surgical follow-up.
T A B L E 5Abbreviation: n, number.a0.4% (n = 1/260) of respondent did not complete this question.JOURNAL OF FOOT AND ANKLE RESEARCH