Stop Coumadin for ingrown toenail procedure?

[ALCapshaw2]

My big toe has a dark coloration around the corner of the nail which is occassionally painful, especially in pressure is applied to the corner end of my toe (as in stubbing my toe or rubbing my toe against my shoe).

My foot doctor's office said that he likes to take coumadin patients OFF their coumadin if he had to make an incision. I'm wondering if this is really necessary?

Are any of you aware of doing foot / toenail procedures while still on Coumadin?

Should I premedicate before having any 'procedures' done to my toe and/or toenail?

I would especially like to hear from Al Lodwick on these issues, but all relevant inputs and/or experiences will be appreciated.

'AL Capshaw'

 

[geebee]

Al,
I have had regular ingrown toenail procedures for years. I do not go off coumadin although the doctor has never had to "make an incision" per se. He has cut down the side of the nail and "worked" the ingrown part out.
The bleeding is usually significant for having nails worked on but never anything he couldn't stop or work around.
I have taken antibiotics when the doctor noticed the ingrown nail was deeper than normal and the procedure would cause more bleeding than normal. My cardio indicated any procedure with "excessive" bleeding requires antibiotics so I guess that is something you should talk to both doctors about. I have also had a time or two where the toe got infected after a procedure (never any pattern to when or how) and I started a regimen of Keflex to get rid of it.
Hope this helps some.

 

[Guest]

Al,

You have an aortic St. Jude valve. I'd try to negotiate for doing the procedure at an INR of 1.8 to 2.0. This should not result in excessive bleeding. It will likely bleed some and need a few bandage changes but it is unlikely to result in needing a transfusion.

I talked with a hematologist about the risk of infection with a similar procedure. His idea was that oozing a little blood was not necessarily bad. The blood would be washing out bacteria that could cause infection. If the wound sealed immediately after surgery there could be a pocket of infection locked in there. The anaerobic bacteria (those that grow where there is no oxygen) are the worst at causing infection.

 

[Ross]

Both of my boys had theirs done and there was very little bleeding to it. I guess it depends on the person doing the job. Yes theirs oozed for a while afterwards, but nothing bad and of course, they were not on Coumadin.

 

[hensylee]

Brother lives in assisted living. Once a month the chiropodist comes in, clips the residents' nails - above and below (fingers & toes). Brother occasionally has an in-grown toenail, but he never goes off his coumadin. Of course, no major cutting has been involved so far.

 

[Gemma]

Jim had an ingrown toenail a couple of months ago - the chiropodist managed to remove a triangular section from the side of his nail without too much damage to the toe itself, although there was a little bleeding. Had a nice big bandage dressed with iodine on for a day, then bathed in salt water every day until it healed. Very good job actually and it was so nice when he stopped moaning about the pain!!
She (the chiropodist) didn't mention stopping the warfarin for the procedure - however I guess it depends just how big an incision is likely, maybe if it's deeper would it cause more problems - Jim's toe bled a little but nothing major. (his INR's 2-3).
Gemma.

 

[Rich]

Hi Al,
I had four nails done late last year,the two big toes were very severely ingrown.
After an intitial visit and some x-rays he had me take an anti-biotic for a period of days prior to the surgery.
He said there was no reason to go off the Coumadin.
After he cut everything out he then used a laser to cauterize all the incisions.
There was some minor bleeding for a few days afterward but no big deal.
The biggest problem was getting my shoes on with all the bandages, yes I know I could have used those special shoes but I wanted to continue doing yard work, remodeling,etc.

 

[Guest]

I had never run across this question before and then today I saw that one of the people in the hospital that I am managing had a toenail removed yesterday. I know that her INR was 2.9 on the day she had it done. I saw the picture in her chart and the surgery report did not mention any excessive bleeding.

 

[ALCapshaw2]

Thanks for all the replies and testimonials.

I made an appointment to have the podiatrist examine my foot and 'take it from there' BUT, when I got there, he refused to see me (he is having an issue with my insurance company...footcare falls under a separate contract from my BCBS) AND because I of course was still on Coumadin. His nurse did examine my toe and confirmed that it is an ingrown nail near the end of my big toe.

It appears that he is firm in his stand that he will not treat my toe until I go off Coumadin for 3 days. His nurse seemed to think that if I had an incision in my toe that I would bleed to death while on Coumadin. Fortunately, my Coumadin Clinic offered to provide bridge therapy with Lovenox if I proceed with this doctor.

There is ONE other nearby podiatrist who accepts my company's foot insurance plan. I left my number with their answering service. If that fails, I will keep looking for someone willing to treat my toe while still on Coumadin. Hopefully someone more knowledgable will agree if I reduce my INR to 2.0 or so.

I STILL get P.O.'d that my surgeon gave me a mechanical valve after we had agreed to a Bovine Pericardial. 15 years without Coumadin and 'adios' still sounds good to me. H*ll, I may not even make 15 years with my mechanical valve but that's another story for another time.

At least I wasn't charged for the visit.

'AL Capshaw'

 

[Guest]

Remember that I can't find a trauma doctor or nurse who can recall an instance of anyone bleeding to death from a cut to the arm, leg or torso. That podiatrist must be planning a huge incision!!!!

 

[Ross]

I often wonder if I'll ever see in my lifetime, Doctors understanding Coumadin. Is this really such a difficult task for them? If we that take it, get it, what is their problem?

Al C I watched both of my sons have theirs done. There is very little bleeding and once the nail is removed, the Doctor applies a cauterizing substance to the area. It still oozes for a little while, but it's not a big deal.

 

[Guest]

I added this to my outrageous advice page.
http://warfarinfo.com/outrageous.htm

 

[ALCapshaw2]

The drama continues...

I located another Podiatrist who WILL treat an ingrown toenail for patients on Coumadin ($150 cash up front since he does not accept my insurance). He reports that he has done many with no problem. I asked about INR and he told me to check with whoever oversees my Coumadin.

Unfortunately, the very knowledgable CRNP at my Coumadin Clinic just accepted a new position and is no longer there and there is no one to fill her shoes at this moment.

My Cardiologist did not want to accept responsibility for setting an acceptable INR and recommended going OFF Coumadin with a Lovenox bridge (to be handled by my Coumadin Clinic).

I made an appointment with my PCP to get his opinion. He will be the FIRST physician to actually examine my toe to assess the condition! I'm feeling no pain (unless I bump or rub the end of my toe) and there is no redness. Hey, it might even just 'grow out' without any treatment. Wouldn't that be nice!

The first podiatrist proposed cutting the entire side off and killing the root (through his nurse), WITHOUT even examining my toe first! He would only agree to see me AFTER I had been OFF Coumadin for 3 days (and NO mention of Bridge Therapy OR Pre-medication!) Unfortunately, he is the ONLY podiatrist in town who is approved by my insurance company (assuming they pay him what they owe and he agrees to continue to accept that company's clients!)

I HATE how so many doctors are afraid of a little bleeding and seem to have NO concern over the risk of STROKE! I guess they figure they can't be blamed for THAT... THAT would just my 'bad luck'.

'AL Capshaw'

 

[Gemma]

Al,
Jeez! I thought they'd at least looked at your toe to be making all these demands about stopping the warfarin!!!
It occurred to me that your toe is probably nowhere near as bad as Jim's was - his was hurting all the time and was quite red where the nail was digging in. Yours may simply require a sliver trimming from the side, perhaps even less than Jim had removed. The chiropodist saw him, took his medical history, and was fine about doing the procedure with him still on his normal warfarin dosage. Was in and out in less than 30 minutes and she only charged him the standard "check-up" fee. His nail is now growing out nicely and doesn't (touch wood) appear to be imbedding itself in his toe again.
Maybe things aren't so bad in the UK after all .
Gemma.

 

[Guest]

No system has cornered the market on good or bad.

 

[Gemma]

True, maybe easier would be more accurate.

Guess we're also lucky he's got a GP, cardiologist and occasional chiropodist who don't subscribe to the "warfarin=bleeding to death from a small cut" school of thought. He's had worse cuts at work than he got from having his toenail dealt with. And made it home to tell me about it in gory detail!

 

[Guest]

No doubt laughing as he recounted the details.

 

[Hank]

Do Not Stop For Toe Job!!

Do Not Stop For Toe Job!!

That is craziness to stop coumadin for a toe job. I had a big time ingrown toe procedure where they removed the whole big toenail permanantly. There was lots of pain and blood and everything else, but nothing a little pressure didn't stop.

I wold NEVER stop coumadin for something like that.

Bleeding can be reversed.

Clotting cannot...

 

[ALCapshaw2]

I had a big time ingrown toe procedure where they removed the whole big toenail permanantly. There was lots of pain and blood and everything else, but nothing a little pressure didn't stop.

Tell me about the PAIN Hank...
Don't the novacaine shots to the toe prevent / minimize that?

I'm beginning to think I may just let this 'grow out' and see what happens since there is no redness or discomfort at present...

'AL'

 

[Ross]

Your toe will be numb and dumb. There will be no pain until that shot wears off, then OUCH!