“My big left toe has had an ingrown toenail for quite some time now, but it wasn’t real bad. There has been no bleeding, bad smell, pus, or discolouration. What happened recently was that I had stubbed my toe and it started to bleed by the nail plate. Couple days later I found an extra amount of skin that was red in the area between the nail plate and the side of the nail. It isn’t a large amount of skin but it’s red and hurts when I touch it.”

Usually patients are a bit frustrated at this point, others go beyond, and think all sorts of things like whether or not they may lose their toe. The “skin” described is called hypergranulation tissue, from an overreaction to the foot stub, or pressure from an ingrown toenail pressing into the flesh. I have seen from 8-year olds to the elderly with this condition. Some persons experience absolutely no pain or discomfort, whilst others complain of extreme sensations. This may actually be a lingering sensation from the stubbing or the ingrown pressure.

The questions/comments usually received at this stage are: “Is there any way to make this extra tissue go away without surgery?” “I’m not sure if it is infected or not, but the extra skin tissue is really bothering me when I walk; is it true that it can never heal?” “Should I try putting my toe in salt water or placing a cotton ball under where the nail touches the skin?” “I really didn’t want to come to you, I thought it would go away, plus I checked Google and YouTube and I was scared. However, with the pain and discomfort there was no other choice”.

What Really is Hypergranulation?

It is also known as overgranulation, exuberant granulation tissue or proud flesh, and usually presents by secondary intention in the wound healing process. Granulation tissue is comprised of new connective tissue and tiny blood vessels, that form on the surfaces of a wound, during the healing process.

It prevents epithelialisation, and the healing process may be arrested. The point at which hypergranulation tissue replaces normal healthy granulation tissue has not been clearly defined, but we can speculate that epithelialisation stops, and the healing process is halted. This is a result of the nature of the hypergranular tissue, which impedes epithelial migration.

Hypergranulation physically impedes epithelial cell movement (raised rolled overgrowth) or, as a result of changes in extracellular signalling, switches off the movement of epithelial cells. This exact mechanism is unclear. The wound generally will not heal when there is hypergranulation tissue. This is because it will be difficult for epithelial tissue to migrate across the surface of the wound, and contraction will be halted at the edge of the swelling.

What are the Characteristics of Hypergranulation?

With regard to clinical recognition, hypergranulation has a friable red, sometimes shiny and soft appearance, that is above the level of the surrounding skin. While there is limited research on the cause of hypergranulation tissue, clinicians have identified a few common characteristics which include:

• moist areas from exudates or bleeding
• prolonged physical irritation or friction with continued repetitive minor trauma or pressure
  • excessive inflammation
• infection
• a new scenario of negative pressure suction, particularly applicable to large pore foam dressings.

Additionally, patients with diabetes are very prone to clinical wound infection. This is due to the inadequate delivery of oxygen and nutrients to the wound bed, which increases the potential for abnormal tissue such as hypergranulation. Also, keep in mind that overuse of occlusive (air or water-tight) dressings, is thought to have an influence as it creates a hypoxic setting. Such a setting causes the body to produce more blood vessels, but some of those are too immature to compensate.

Differentiating Between Hypergranulation Tissue and Malignancy

Clinicians may mistake a malignancy for overgranulation. If there is any suspicion that this is not normal, one should obtain a biopsy. There will be some clinical clues as follows:

• The overgranulation has been present for many months.
• It has a cauliflower appearance or is hard to touch.
• It is growing outward beyond the wound margins.
• It does not respond to any of the treatments below.

Possible Treatment Options for Hypergranulation Tissue

• Silver nitrate – When activated, this is a caustic material that oxidises organic matter, coagulates tissue and destroys bacteria. Tissue dies almost immediately. Unfortunately, this sets up further inflammation and exudate formation.
• Vapor permeable dressing – A non-occlusive dressing, such as a foam dressing, with light pressure application can be effective.
• Sharp debridement of the area is extremely successful at removing the hypegranulation tissue, but not successful at preventing recurrence.
• Low-dose cortisone cream – Topical corticosteroids are not approved or indicated for open wounds, but can be used on hypergranulation tissue, depending on the location. This method of treatment is not always successful.

Your feet mirror your general health . . . cherish them!