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.