Granulation tissue and ingrown toenail

Wearing shoes that are too tight, narrow, rigid or high-heeled is one of the most common causes of ingrown toenail granulomas. Excessive pressure on the foot creates mechanical conflict between the nail and the surrounding tissue, allowing the nail edge to penetrate the skin and trigger local inflammation.

Safety shoes or footwear not adapted to the natural shape of the foot may also contribute to the problem.

Improper nail trimming — particularly when nails are cut too short or unevenly — can lead to inflammation and sometimes infection.

Poor foot hygiene or difficulty maintaining proper nail care increases the risk of complications.

Older adults, people with significant overweight, or those with limited mobility may have difficulty trimming their nails correctly, which increases the likelihood of developing an ingrown toenail with granuloma.

Intensive sports activity may cause the foot to swell, increasing pressure on the toes inside the shoe.

Repeated impacts, micro-trauma, or direct injury to the toes may also trigger or worsen the conflict between the nail and surrounding skin.

Certain medical conditions or anatomical characteristics may increase the risk of granuloma formation:

• Diabetes, which can impair wound healing
• Abnormal growth of the skin surrounding the nail
• A particular nail shape or thickness more prone to ingrowth
• Foot alignment disorders such as hallux valgus or forefoot pronation

By definition, a granuloma causes the development of a small red growth of tissue, sometimes shiny or moist, located along the edge of the nail. This mass may gradually increase in size and become visible above or around the nail.

The affected area is often painful, particularly:

• when pressure is applied
• when wearing shoes
• during walking or physical activity

The pain can become constant when inflammation persists.

Granulation tissue is fragile and can bleed easily, even with minor friction from socks or shoes.

Other signs may include:

• redness around the nail
• local swelling
• warmth of the affected area

If a local infection develops, clear or purulent discharge may appear. This may be accompanied by increased pain, inflammation, and functional discomfort.

These symptoms may make it difficult to wear shoes, limit walking, and significantly affect quality of life, especially when the granuloma has been present for several weeks.

At this stage, discomfort or mild pain is present but without infection.

Specialised podiatric care is usually sufficient. This involves removing the portion of nail penetrating the skin and correcting the nail trimming technique to reduce recurrence risk.

This treatment is simple, non-invasive, and often highly effective when performed early.

When inflammation is associated with infection but without visible tissue growth:

• regular dressings are applied
• local foot baths and wound care may be recommended
• medical treatment may be prescribed

Close monitoring is required. If conservative treatment fails or the problem recurs, surgical treatment may be considered.

At this stage, the ingrown toenail is associated with a granuloma (also called pyogenic granuloma), a benign red lesion that bleeds easily.

Initial treatment may include:

• medical management
• cauterisation with silver nitrate
• antibiotic therapy if infection is present

If these treatments are insufficient, a surgical procedure may be recommended.

The lateral portion of the nail responsible for the conflict with the skin is removed. This targeted procedure is usually performed under local anaesthesia.

The granuloma is completely removed and the surrounding skin is reshaped to promote optimal healing.

Part of the nail matrix (the area responsible for nail growth) is removed in order to permanently narrow the nail. This allows durable treatment of the underlying cause and significantly reduces the risk of recurrence.