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Involuted Toenail
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An involuted toenail is one that is overly curved across its width. The most severe form, a pincer nail, affects nearly 1 in 100 people, usually on the big toe. It often causes no pain, but for some people it becomes sore, red and swollen, and it can make shoes and walking uncomfortable. Care is available, from gentle home measures to treatment from your podiatrist, though the curve can return over time.
What is it?
An involuted toenail (a curved toenail) is overly curved from side to side.
The most severe form is called a pincer nail, where both sides of the nail curve towards each other. The curve tightens from the base of the nail to the tip, so the nail gets narrower and higher.
An ingrown toenail is named for its symptoms, and the nail has a normal shape. A pincer nail is named for its shape. So look at the shape of the nail as well as how it feels.
These names are used loosely. "Involuted" is sometimes used for any curved nail, while "pincer" is kept for the severe form. Much of the advice here is for ingrown or pincer nails, so it applies to involuted nails partly by comparison.
Who does it affect?
Pincer nail affects nearly 1 in 100 people. It most often affects the big toe. Other toenails and fingernails are affected much less often.
Many people first notice it in adulthood, when the nail slowly becomes more curved over time. It often stays painless, but some people have severe pain and need treatment. Narrow or high-heeled shoes may be one reason the big toe is affected most.
Signs and symptoms
Many people first notice the nail slowly curling in at the sides. In a pincer nail, the nail can curl so far that it forms a tight tube. This often stays painless. Some people, though, have severe pain.
When it is sore, the pain usually starts as minor discomfort and builds over time. The toe may look red, swollen and inflamed, and the nail pinches the skin beside it. It usually affects the big toe, but any toe can be involved.
The curve can make shoes hard to wear and walking uncomfortable. In some people it brings long-lasting inflammation or infections that keep coming back.
If your toe is sore, look at it each day. Check for pus, spreading redness, warmth, swelling, or a new smell or discharge. Signs of infection are covered in the "When to see a podiatrist" section below.
What causes it?
The cause isn't known. A curved or pincer nail may be inherited (passed down in families) or acquired (developing later in life). Inherited pincer nails tend to be symmetrical, whereas acquired ones are asymmetrical.
Several things are linked to it. Poorly fitting shoes are thought to be one of the most common causes. Repeated pressure or injury to the toe, and a fungal nail infection, may also play a part. Some skin conditions, such as psoriasis, are linked to it. So are some general health conditions, and some medicines, including beta-blockers (used for heart problems and blood pressure). When a linked health condition is well controlled, the nail can settle by itself.
Tell your podiatrist or doctor about any regular medicines, skin conditions, fungal nail infection and past toe injuries. Please don't stop a prescribed medicine because of a nail change. Talk to the person who prescribed it first.
How is it diagnosed?
Your podiatrist or doctor will look at your feet and nails. A pincer nail is recognised by its shape: the curve tightens from base to tip. They will also check for pain, redness, swelling and hard skin, and for signs of wider health problems.
An ingrown nail has a normal shape. Retronychia is another look-alike: it mostly affects the big toe, with a nail that stops growing and grows into the skin at its base.
Note which toes are affected, whether one or both sides curve in, and how the pain has changed. Bring your medicines and conditions list.
Treatment
There is no agreed first choice of treatment. For a pincer nail, gentle (conservative) care usually comes first, because surgery can leave the nail permanently changed. The trade-off is that the nail may curve again or need more treatment later.
Looking after it at home
Wear wide, comfortable shoes or sandals with room at the toes. Keep the nail a little longer and don't trim down the sides.
Soak the affected toe in warm, salty water for 10 to 20 minutes, 3 times a day, for 1 to 2 weeks. Then keep the foot dry. Paracetamol or ibuprofen can ease the pain, if they are suitable for you.
If you have diabetes, poor circulation, nerve damage in your legs or feet, or lowered immunity, please don't treat a problem nail yourself. Infection is more likely and can become serious.
Treatment from your podiatrist
Taping is the gentlest option. It pulls the skin away from the nail edge and can help mild cases if it is done correctly and consistently. A small piece of cotton or dental floss under the nail edge can keep it off the skin.
A nail brace (a thin steel wire or plastic band) opens up the curve and is mainly used for pincer nails. Gutter splinting is another option. Ask your podiatrist to show you correct taping, packing or brace use before you start.
Other options
For pincer nails, a gel called acetylcysteine can be used together with a brace. Side effects were mostly mild, and none were linked to the gel.
Surgery
Partial nail removal with phenol (surgery on the nail root) is another option. For ingrown nails, surgery is better at stopping the problem coming back than gutter splinting, and probably better than a brace. Phenol seems to lower the chance of it returning, though it may not clearly beat splinting.
Surgery can permanently change how the nail looks, and rarely it has other risks. Ask about the chance of it coming back, healing time and any risks before you agree.
Recovery
A pincer nail is a long-term problem that keeps coming back. Gentle care is simple, but it may bring only temporary improvement, and the nail may curve in again over time. This can affect daily life, including the shoes you can wear and how comfortably you walk.
If a curved nail is linked to a general illness, it may settle by itself once that illness is well controlled.
Preventing it
A few everyday habits may help. Cut your toenails to the shape of the toe. Don't round off the corners, and don't cut them too short.
Wear well-fitting shoes, and check that they aren't narrow or pressing on your toes. If the nail keeps coming back, see the "When to see a podiatrist" section.
When to see a podiatrist
When to book
Book an appointment with your podiatrist if:
- your pain hasn't improved after a few weeks of home care
- your symptoms keep coming back
- foot pain is stopping you from doing your usual activities
- you can't find comfortable shoes, or a lump or bump on your foot makes shoes hard to wear
- the skin around your nail is red, swollen, sore or warm, or there is pus around it
- you have an ingrown toenail
- you have diabetes or poor circulation and a long-term foot problem, such as a bunion, corns or thick nails
When to get help sooner
Call your local emergency number if:
- you have a foot wound, ulcer or infection and also feel very unwell, with confusion or slurred speech, severe shivering or muscle pain, severe breathlessness, mottled or discoloured skin, or little or no urine (possible sepsis)
Get urgent medical assessment (see your GP today, or go to an urgent care clinic or the nearest emergency department) if:
- redness from a wound, sore or infection is spreading into your foot or leg, or red streaks run up from it
- you have a foot wound, ulcer or infection, or a red, hot, swollen foot, and also have a fever, chills, a fast heartbeat or feel unwell
- your foot, or a patch of skin on your foot or leg, becomes red, hot, swollen and painful
- you have diabetes or poor circulation and signs of infection in your foot, toe or nail, such as redness, warmth, swelling, pus, a bad smell or more pain
- you have diabetes, poor circulation or reduced feeling in your feet and notice a new wound, sore, blister or colour change on your foot, or a sore that isn't healing
- you have diabetes or poor circulation and an ingrown toenail
- you have pain in a bone with a fever
See your GP soon if:
- a spot, mole or sore on the skin of your foot or leg is new, changing, bleeding or not healing
See your podiatrist or GP soon if:
- an infection is getting worse, with more pain, redness, swelling or pus, but the redness isn't spreading and you feel well
Frequently asked questions
Is an involuted toenail the same as an ingrown toenail?
Not quite, though the two often occur together and have been confused for decades. An ingrown toenail is named for its symptoms. An involuted or pincer nail is named for its curved shape. You can have one without the other.
Does a curved toenail run in families?
Sometimes. The symmetrical form of pincer nail is probably passed down in families, with the bone at the tip of the toe thought to be involved, though the causes are still debated. Pincer nails may also be acquired rather than inherited.
Can I dig out or cut down the side of the nail myself?
It's best not to. Picking at the nail, cutting down its sides or digging with a sharp tool can damage the nail or skin and lead to infection. Your podiatrist can safely tidy a curved nail for you.