Step-by-Step Procedure

1. Preparation and Assessment

• Patient comfort: Ensure the patient is in a comfortable position, preferably supine with the affected foot elevated for visibility and access.
• Hygiene: Sterilize the area thoroughly using antiseptics like povidone-iodine or chlorhexidine.
• Anesthesia: Administer local anesthesia (e.g., digital block with lidocaine) to minimize pain during the procedure.

2. Decompression of the Area

• Elevation of Nail Fold: Use a sterile blunt instrument (e.g., nail elevator) to gently lift the edge of the ingrown nail from the inflamed soft tissue.
• Drainage if Necessary: If the granuloma is exudative, gently drain any pus or serous fluid to relieve pressure.
• Reduce Swelling: Apply gentle pressure around the inflamed area to decompress accumulated fluids or infection.

3. Removal of Spicule (Nail Fragment)

• Identification of the Spicule: Carefully inspect the edge of the nail to locate the spicule causing irritation and embedding in the soft tissue.
• Trimming: Use sterile nail nippers to trim and remove the spicule, ensuring you do not leave any sharp edges or remnants behind.
• Smooth the Nail: File the edge of the nail to prevent further trauma to the surrounding tissue.

4. Granuloma Management

• Debridement: If the granuloma is prominent, gently excise it using a sterile scalpel or curette. Avoid excessive bleeding by applying pressure and hemostatic agents as needed.
• Topical Application: After debridement, apply an antibiotic ointment or silver nitrate to promote healing and prevent infection.

5. Post-Procedure Care

• Dressing: Cover the area with a sterile dressing to protect it from contamination.
• Pain Management: Prescribe or recommend appropriate analgesics and anti-inflammatory medications.
• Follow-Up: Schedule a follow-up visit to monitor healing and ensure no recurrence of the ingrown toenail.

6. Preventive Recommendations

• Encourage the patient to wear comfortable, open-toed shoes during the recovery period.
• Advise proper nail-cutting techniques (straight across, avoiding curves) to prevent future ingrown nails.

---

Caution:

• Avoid aggressive removal of the granuloma or excessive nail trimming, as this may exacerbate tissue damage or prolong recovery.
• In cases of severe infection or recurrence, consider a partial or total nail avulsion with phenolization to prevent regrowth of the problematic nail edge.