Great Toe Nail Removal: Clinical Indications

Primary Indications

The American College of Foot and Ankle Surgeons recommends partial or complete nail removal for recurrent, severe, or treatment-refractory ingrown toenails after conservative measures have been exhausted, with a strength of evidence based on clinical guidelines 1
Mechanical nail removal is indicated when dense white lesions (dermatophytomas) develop beneath the nail, as these compact fungal masses prevent antifungal drug penetration, according to the Infectious Diseases Society of America 1
Surgical avulsion followed by topical antifungal therapy for single-nail onychomycosis showed disappointing results in randomized controlled trials and is NOT recommended as routine treatment, based on evidence from the American Academy of Dermatology 1
Debridement alone cannot be recommended as treatment for onychomycosis, as stated by the American Podiatric Medical Association 1

For diabetic patients at risk of foot ulceration, digital flexor tendon tenotomy rather than nail removal should be considered as first-line surgical intervention, according to the International Working Group on the Diabetic Foot 2
Ingrown or thickened toe nails in diabetic patients require immediate treatment by an appropriately trained healthcare professional to prevent ulceration, as recommended by the American Diabetes Association 2
Assess for signs of infection or poor circulation before proceeding with any nail removal in diabetic patients, as they have a higher risk of complications, according to the American College of Foot and Ankle Surgeons 3

Complete nail avulsion for fungal infections should not be performed as routine treatment, as the evidence shows disappointing results, according to the American Academy of Dermatology 1
Nail removal in diabetic patients should not be performed without first assessing vascular status and infection risk, as recommended by the American College of Foot and Ankle Surgeons 3
Ensure procedures are performed only by appropriately trained healthcare professionals, as improper technique can cause harm, according to the American Podiatric Medical Association 2