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Surgical Approach to Harpoon Nail: A New Variant of Ingrowing Toenail We report a very unique form of ingrowing toenail, where the lateral offending nail spur harpoons the lateral wall until it emerges at the distal tip of the digit. To the best of our knowledge, this type of ingrowing toenail, as well as its specific surgical approach, has never been reported. Development of ingrowing toenails results from an epidermal breakage in the lateral nail sulcus. Constant pressure from the nail plate against the soft tissues in a narrow shoe, especially if the nail is cut short, may push up the distal pulp, resulting in a painful distal corner. To alleviate discomfort, the patient starts to dig with nail clippers in the lateral nail fold and is unable to clip the most lateral and deep part of the plate, thus leaving a spur, especially in patients with marked constitutional transverse curvature (Figure 1).1,2

Figure 1. Harpoon formation.

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In some exceptional instances, the spur will grow distally and run through the disto-lateral wall to finally emerge at the hyponychium. At the acute stage, stage II or III from Mozena,3 clinical presentation due to classical ingrowing toenail is associated with erythematous and oozing, sometimes crusted, papule, which corresponds to the emergence of the spur through the epidermis in the lateral and distal wall (Figure 2A, B). This papule is facing more or less the lateral sulcus. If not treated, a chronic form may develop: the inflammation disappears because of the epithelialization of the canal that contains the spur (Figure 3). Surgical treatment is indicated and should first consist in deroofing of the canal. This procedure is completed

Figure 2. Acute form: erythematous and oozing scabby papule at the emergence of the harpoon nail. (A) mild; (B) severe.

DERMATOLOGIC SURGERY

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resulting from severe osteoarthritis. Eleven of them exhibited an acute stage (painful erythematous and swollen papule on the disto-lateral wall), and 2 were in a chronic stage, with only a keratotic tip emerging from a normal distal wall. These 2 patients reported acute episodes of ingrowing toenail for several years, which healed spontaneously in the last months. They were seeking medical advice to avoid recurrences of such painful flare-up. Figure 3. Chronic form without any inflammation after epithelialization of the canal.

by the avulsion of a lateral strip of nail plate followed by a chemical cautery of the exposed lateral matrix. Other options would include a wedge resection carrying out the lateral fold with the spur in its canal, a VandenBos’ procedure, or a SuperU, which debulks all periungual soft tissues and exposes the hook-like piece1 (Figure 4). We had the opportunity of encountering 13 cases of “hook nails” over the past 4 years. All involved the great toenails, except one that was located on the index finger, which was affected with a pincer nail

Nine acute cases and the 2 chronic forms benefited from deroofing of the canal associated with wide classical chemical matricectomy. Two very severe acute cases, stage IV, 4 had wide debulking of the excessive soft periungual tissues. No recurrence was observed in a follow-up of more than 1 year. References 1. Richert B. Surgical management of ingrown toenails- an update overdue. Dermatol Ther 2012;25(6):498–509. 2. Haneke E. Controversies in the treatment of ingrown nails. Dermatol Res Pract 2012;2012:783924. 3. Mozena JD. The Mozena classification system and treatment algorithm for ingrown hallux nails. J Am Podiatr Med Assoc 2002;92 (3):131–5. 4. Martínez-Nova A, Sánchez-Rodríguez R, Alonso-Peña D. A new onychocryptosis classification and treatment plan. J Am Podiatr Med Assoc 2007;97(5):389–93.

Bertrand Richert, MD, PhD Marie Caucanas, MD Dermatology Department University Hospitals Saint-Pierre Brugmann and Children’s University Hospital Queen Fabiola Université Libre de Bruxelles Brussels, Belgium

Figure 4. Deroofing of the canal exposes the offending hook-like piece.

Nilton Di Chiacchio, MD, PhD Clinica de Dermatologia do Hospital do Servidor Publico Municipal de São Paulo São Paulo, Brazil

40:6:JUNE 2014

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Surgical approach to harpoon nail: a new variant of ingrowing toenail.

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