4 | DISCUSSION
Anxiety is a feeling for situations of uncomfortable expectations. Surgery may create anxiety for patients, and it may sometimes cause refusal of the intervention necessary for diagnosis and/or treatment of diseases. There are many factors that affect people’s anxiety, and awareness of these factors allows us to understand better the biological, psychological and social status of the patient we are going to intervene and help them in a better way.
Nail surgery is performed for both diagnostic and therapeutic purposes. Ingrown toenails –Onychocryptosis- is a common cause of nail surgery.10 It is formed due to the lateral folds of the nail entering the surrounding soft tissue and curving of the nail plate. It causes discomfort and pain which may prevent walking of the patients, and besides, it may lead to poor quality of life and may contribute to anxiety and depression. 11 In the treatment of the disease, as in our nail surgery practice, lateral nail avulsion with chemical matricectomy with 88% phenol is performed.12, 13
It is known that all surgical interventions can cause anxiety, whether in local anaesthesia or in general anaesthesia. In the melanoma sentinel lymph node sampling, the patients’ blood cortisol level has been shown to correlate with anxiety; In addition, patients in local anaesthesia have higher blood cortisol levels; thus anxiety is higher than patients with general anaesthesia.14
Dermatosurgical interventions can be evaluated as day surgical interventions under local anaesthesia. Interestingly anxiety levels of our patients who underwent nail surgery were close to the anxiety of the patients who underwent breast biopsy or bone marrow biopsy15, 16 .
Göktay et al. stated that what patients fear most is the needle.17 In the literature, it is reported that needle-free anaesthesia options are also available for patients with needle phobia.6 In our study, approximately half of the patients stated that what they have a fear of the needle. However, In our study, patients reported that they feared mostly for the recurrence of the disease after the procedure. As far as we know this is the first study questioning of recrurrence.
Ingrown toenails have an impact on the quality of life that ranges from moderate to severe. 18 There are studies showing the effect of the disease on quality of life and the change in life quality after nail surgery. 18, 19 Ingrown toenails cause pain, inflammation, infection, limitations in daily activities, and promote school and work absenteeism, which directly affects the patient’s quality of life. 18 In a study about ingrown toenails, the patient with the female sex, younger age and severe clinical classification had a higher impact on quality life scores.18 We observed higher functional Skindex-16 levels in the 31-50 years age group in our study, but we did not observe any relationship with sex. It was considered that this age group was active in working life. As shown in the study of Chren et al., Functional skindex levels are found in ingrown nail as well as eczematous dermatitis, while higher functional skindex levels are observed in basal cell carcinoma, actinic keratosis and benign gowths20.
Sociodemographic characteristics that might affect anxiety levels among patients and awareness of these factors can be a guide for clinicians’ approach to the patients. Göktay et al. did not find a difference between anxiety levels and the patients’ age, gender and educational status 17. Cooke et al. found that the preoperative mean anxiety score was independent of the patients’ age, sex and even the type of surgical procedure (orthopaedics, skin, breast, general, urology, other) in patients scheduled for daily surgery.21 Augustin et al. reported that anxiety was higher in female patients undergoing nevus excision; however, they showed that this score is independent of age. 22 In our study, contrary to these publications, preoperative state anxiety of the male patients was significantly higher than female. Apart from sociodemographic characteristics, the waiting time until the procedure may also affect the anxiety levels. When the female patients who were planned to have a biopsy for the breast were evaluated, it was found that anxiety increased with increasing waiting time in patients.23, 24 However, in our study, there was no significant difference in anxiety scores between genders according to the waiting time.
The state-anxiety scale evaluates present anxiety level; the trait-anxiety scale evaluates general states of calmness, confidence, and security. Wetsch et al. revealed that state anxiety mean scores of day surgery patients were found to be higher than their trait anxiety mean scores. 25 Alacadag et al. found that the state anxiety scores lower than the trait anxiety score in patients who were scheduled for daily surgery. 26 In our study, it was observed that the state anxiety score was lower than the trait anxiety score, and no correlation was observed between the two scores. This suggests that patients are worried about interventional procedures, regardless of their average level of general concern.
In the literature, it was emphasized that there is a relationship between pain scores in surgical procedures and anxiety, and therefore, it is necessary to be paid attention for reducing anxiety levels of patients in order to they feel less pain. 15, 27-29 In a study evaluating the influence of the preoperative emotional state on postoperative pain after orthopaedic and trauma surgery, patients with high presurgical anxiety had more pain afterwards.30No similar relation was observed in our study. However, in our study, preoperative pain score was negatively correlated with preoperative anxiety. This can be explained by the fact that patients want to be treated as soon as possible, as the disease affects the quality of life and working lives of the \soutyoung working population.
Experiences in human life can affect our emotions and behaviours, and this is also valid for interventional surgical procedures. In our study, the preoperative STAI-S scores of those who had undergone dermatological surgery (other than nail surgery) were statistically significantly lower than those who did not have a history of previous dermatological surgery, but there were no significant differences in anxiety scores between first-timers and patients with previous nail surgical experience. Göktay et al. did not see any significant difference between first-timers and patients with previous nail surgery, but they did not question other dermatological interventional procedures.17
Even in imaging-guided breast procedures women’s anxiety level was reported to decrease but not be eliminated after the biopsy, Miller at al. mentioned not just the intervention itself; also uncertainty related to biopsy result may create anxiety.16 Unlike this and other reported studies, our patient population showed higher postsurgical anxiety than presurgical period (STAI-1: 39,5 vs 44,2). It was an unexpected result for us. This situation; it shows how much anxiety the nail surgery, which is considered as a torture method even in antient time, can cause anxiety in the life of the individual regardless of before and after nail surgery. Also, the score was measured immediately after surgery; it could maybe be better to score anxiety level after a while.
The limitation of our study was that other nail surgery applications except for nail avulsion were not included in the study. However, some of these interventions are performed for diagnostic purposes. This group was not included in the study because of the concern that the biopsy result may be malignant, and it may also affect the levels of anxiety.