Toenail Bracing Complicated With Group-A Beta-Haemolytic Streptococcus Infection

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Ingrown toenails are one of the most frequently diagnosed nail disorders in adolescents, with great impact on the quality of daily routine activities, associated with pain and frustrating therapies.
Conservative and surgical methods are nowadays available to cure the disease: taping, packing, and dental floss inserted under the nail margin,1 gutter treatment2 (small guard inserted between the lateral nail margin and the nail fold), nail braces3 (steel wire or plastic bands applied to correct the nail curvature), phenolisation, and surgical wedge resection.
Nail bracing is a conservative method used for ingrown nails; its mechanism is based on lifting the nail edges and alleviating pressure on the surrounding tissue. It is used worldwide, well tolerated by patients; minor pain has been described in some cases.
A 15-year-old teenager with a long medical history of ingrown toenail, with nail bracing applied 2 months before presentation was seen in Emergency for local pain, fever, and intense inflammatory reaction on the lateral edge of the nail (Figure 1A). She denied any previous local trauma. Good hygienic measures had been applied during the application of the nail bracelets. Clinical examination raised the suspicion of bacterial infection around the nail.
Antistreptolysin O and antistreptokinase were increased, erythrocyte sedimentation rate was elevated; leukocytosis and C reactive protein positive were observed. A small tissue fragment was taken and sent for bacteriological examination. Group-A beta-haemolytic Streptococcus was isolated and penicillin therapy was started immediately for 10 days with positive results. Bracelets were not removed during and after the antibiotic therapy (Figure 1B).
Nail bracing is a conservative method used for ingrown nails: Steel wires are applied over the dorsal surface of the nail and curved under its lateral edges. The position of the bracelets is modified monthly according to the symptoms of the patient and the presence of local inflammation and granulation tissue. The nail braces, made of steel wire, are hooked under the lateral edges of the over curved nails. The braces are completely removed within months when the aspect of the nail returns to normal, and no sign of inflammation is noticed.
Generally, this conservative method is very well tolerated and represents a good alternative to surgery, especially in children.4
This is the first case described in the literature of a Group-A beta-haemolytic Streptococcus infection occurring in an ingrown toenail treated with conservative method (nail bracing), after 2 months of therapy in a teenager, who respected all hygienic measures.
The present case highlights the possibility that bacteria can invade the skin through a minor trauma because of bracelets. Another explanation resides in the pathogenesis of the ingrown nail itself: a tiny spicule of the nail pierces the skin and induces a foreign body reaction with secondary infection. In any case, nail bracing should not be abandoned, systemic antibiotics, and simple hygienic measures could favour good evolution of transitory bacterial infection.
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