Phenol and Nail Surgery

Behind the Scenes - when phenol may not be the best selection for nail surgery

Although first written in 2021, the diversity of questions on a podiatry Facebook page relates to the all-too-common query about ingrowing toenails and their failure to respond to treatment with the chemical phenol, with nail surgery.

ConsultingFootPain is as much about promoting professional development for podiatrists as it is for supporting patients and foot health.

There can be no more excellent reflection than reading answers from professional podiatrists offering a wide range of experience. This article is based on nasty-looking toes that won’t seem to heal.

This article will feature:

• Medical risk

• Incorrect selection

• Poor Healing

Failure after phenol

There are three ways to deal with a toenail that causes characteristic inflammation: the cherry red covering of hypergranulation, pain, suppuration and offensive odour. The questions we must ask are: Treat conservatively, apply a chemical to destroy the growth cells called the matrix or remove a soft section of the toe.

The diversity of the query arises when a clinician is unsure about the best course of action. Three scenarios provide a composite view and options:- patients present as follows.

1. With known medical problems and diabetes. 

2. Recurring regrowth after several attempts.

3. Despite being treated for regrowth with antibiotics and nail surgery, the toenail remains unsightly.

Case 1 –  Medical Risk

In case (1), there is a dilemma.

The clinician wants to use phenol but is unsure if it could put the patient at risk. The advice was wide and varied from a Facebook audience. The majority believed that if the circulation is fine and if the blood analysis for diabetes is stable, phenol should be fine.

The corollary is that the patient should be informed of the risks, and it is implied that this will safeguard a decision. Should we treat diabetics in the same way as non-diabetic patients? Many podiatrists use phenol, but hopefully, this decision is based on a thorough healing assessment and diabetic stability. 

Here are three counter corollaries

All tissue is different, and because healing is the concern, phenol can impede healing. This recalcitrance to recover, say, within a 10-21-day period, can be extended for months. There is a straightforward answer for any person wondering whether to proceed. This is taken from a post (Berms, 2008) from a different podiatry UK site.

'(I) I have probably done 150 or more nail procedures/surgeries in the last 5-10 years, and I haven’t had any real adverse reactions or complications so far.

However, I did a partial nail avulsion and chemical cautery (with phenol) on the left Hallux nail of a healthy 12-year-old. She had no reported allergies and no regular medication…

She is complaining of a lot of pain post-op (4 days) and has a large “white area” (her words) around the wound site. The original phenol was flushed with alcohol and the toe was dressed with povidone iodine ointment. She has been redressing herself since day 3.

She is coming in today for me to have a look, but I thought I might get an idea of what I might be looking at. I have had some phenol reactions before, but they are usually small and red in colour.

Any advice is appreciated.' Berms, Apr 30, 2008

Where was the evidence?

The question sought suggested that phenol could have a lethal effect—months of despair, dressings, depression, loss of limb and maybe death. The response from Podiatry Arena suggests that risks are low. There has been a presumption that one can use a specific ‘duration time’ for every patient. This is taught in undergraduate school and is broadly correct, but for one fact.

All tissue is made up of a specific DNA recipe, and therefore, allergies, sensitivities and reactions to what is, after all, a caustic burn can arise. If there is an unknown, one should remove that risk. You have to deal with pain and infection and healing. Remove the section or whole nail and let it reoccur, but monitor the healing. Remove the risk from unknown phenol reactions.

Reflection

My colleague and I ran a surgery programme, and we took this same view. If in doubt, do less. Sadly, on one occasion, we noted a case of a diabetic (that we had not operated on) who went on to have a leg amputation following a phenolisation. Without question, this was the problem created by phenol saturation. That was nearly 30 years ago.

I have seen delayed healing, burns and skin damage due to accidental phenol application elsewhere. The literature is not particularly good at recording evidence, and this is where case history, a bit like case law, comes in.

Podiatry Today published an article in 2020 (accessed 25/1/25) of interest, but it does not open up the debate despite being recent. Many citations are outdated, with the newest one being from 2015. Turning to the Royal College of Podiatry database, PASCOM data does not sustain sequellae in large numbers. We conclude that regrowth, infection and other such problems are low. In other words, we are taking it as read that this is the case when, in fact, much underreporting probably exists.

In a 5-year data capture, n= 61 nail phenolisation cases from ALL groups had a regrowth of 2.1%. However, in the smaller number of 26 cases that had diabetes alone, 10.3% had a recorded infection, and 5.1% had regrowth with phenol. Source PASCOM accessed 19/01/21

Case 2 – Incorrect Selection 

Where phenol surgery has failed, it is easy to suggest that the clinician is at fault. There are reasons that phenol can fail. There is a case where some patients do not respond to this form of management.

Two attempts would seem reasonable before taking on the alternative, such as a nail matricectomy by resection and suture. Never be afraid to say, "I cannot" or "I don’t know."

The basis of Hippocrates’ Oath (not that podiatrists take the oath) can be trimmed down to two associated clauses:

I swear to fulfil, to the best of my ability and judgment, this covenant: …I will apply all measures [that] are required for the benefit of the sick, avoiding the twin traps of overtreatment and therapeutic nihilism. …I will not be ashamed to say, “I know not,” nor will I fail to call in my colleagues when another person’s skills are needed for a patient’s recovery.

Good knowledge of micro-organisms affecting the skin is important when selecting treatment

Case 3 –  Poor Healing

The case of a patient with poor healing and infection was particularly enlightening in the most recent discussion on this topic.

The responses came back as most likely S.Aureus, which is true, but there is a case for focal infection that can be overlooked. Secondly and more bizarre is the self-harm side. If antibiotics fail, it is usually due to the wrong dose or the wrong antibiotic being present for the organism.

In this case scenario, the author found that a patient had failed to respond. Culture is mandatory in these circumstances. In one of my cases in 2009, Flucloxacillin PO 500mg qds was prescribed but failed.

Prevotalla melanogenic was identified as arising from a dental gum infection and treated with metronidazole when it was then cleared. This was put down to focal infection.

The second case of non-healing occurred when the young female patient (adolescent) had a case of onychotillomania, i.e picked at her nail tissue obsessively.

Never underestimate neuroses surrounding conditions that do not seem to do well.

Alternative Thoughts

I have been asked about sodium hydroxide as an alternative to phenol. Both are toxic, and my own advice to podiatrists would be one of caution. Unfortunately, we cannot patch test, and the alternatives include excisional matricectomy, which is not part of mainstream care provided by most podiatrists in the UK. It would be useful to have a register of podiatrists offering the Winograd procedure.

The Unspoken Career of Podiatry. Now Available highlights some of the work of colleagues in the UK. Available from Amazon Books.

Summary

Evidence is essential and always will be.

PASCOM data is far from ideal and needs to be collected prospectively with tighter controls. There, again, PASCOM supports clinicians in reflecting on their practice as was always intended.

Modha, R.(2019) provided helpful insight into the system for nail surgery capture. We take home that healing problems are not down to the clinician alone. Problems may be associated with different tissue types.

No study to date has provided a conclusive distinction between tissue types, but the female-male gender gap in health is more relevant now than ever. Likewise, for the sake of avoiding risk, stay safe and do not use phenol if you are uncertain. 

Although the risk may appear low, we cannot rely on small data sets without robust scientific techniques. Poor healing may be due to the patient or a focal infection.

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Thanks for reading this article –  Phenol and Nail Surgery by David R. Tollafield.