From the Guidelines
For an ingrown toenail developing after successful terbinafine treatment for onychomycosis, I recommend warm foot soaks in Epsom salt solution (1 tablespoon per quart of water) for 15-20 minutes, 2-3 times daily, as this can help soften the skin and nail, making it easier to manage the ingrown nail 1. After soaking, gently try to place a small piece of dental floss or sterile cotton under the corner of the nail to lift it away from the skin. Apply an antibiotic ointment like bacitracin or neosporin to prevent infection and cover with a bandage. Wear open-toed shoes or sandals temporarily to reduce pressure. If you cannot get the cotton under the nail or if there's significant pain, redness, or discharge, see a podiatrist or physician promptly as partial nail removal may be necessary. This situation occurs because new nail growth sometimes follows an abnormal growth pattern after fungal infection clears, causing the nail to grow into the surrounding skin, as noted in the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1. Proper nail trimming (straight across, not rounded at corners) can help prevent future ingrown nails once this episode resolves. It is also essential to emphasize the importance of preventive measures, such as wearing protective footwear, applying antifungal powders, and keeping nails short, to avoid re-exposure to fungal elements 1. Some key points to consider in managing onychomycosis and its complications include:
- The high recurrence rates of onychomycosis (40-70%) and the importance of achieving fungal-free nails as the goal of antifungal therapy 1
- The potential for treatment failure due to factors such as nail thickness, slow outgrowth, and dermatophytoma 1
- The need for proper nail specimens and laboratory diagnosis to maximize treatment efficacy 1
- The importance of monitoring and reassessing patients for mycological cure, particularly high-risk patients 1
From the Research
Onychomycosis Treatment and Nail Care
- The patient has been treated with terbinafine for onychomycosis for 6 months, and the nail is growing out, with the new nail digging into the skin 2.
- The fungal nail has fallen off, and the new nail is causing discomfort, making it difficult to get cotton under it.
- According to a study published in 2020, oral terbinafine is the treatment of choice for onychomycosis, followed by oral itraconazole 2.
- Topical monotherapy can be considered for mild to moderate onychomycosis and is a therapeutic option when oral antifungal agents are contraindicated or cannot be tolerated 2.
Nail Care and Protection
- A study published in 2021 found that most nail care providers use some form of self-protection when filing, trimming, or using a rotary tool on patients' nails, but approximately one-fourth of respondents reported offering some type of protection for patients 3.
- The study suggests that patient/client protections should closely mirror the personal protective equipment used by the nurse, and future research is needed to contribute to a national consensus guideline for best practices and protections at all levels of nail care 3.
Diagnosis and Treatment Efficacy
- A consensus project published in 2022 provides recommendations for the diagnosis and assessment of distal lateral subungual onychomycosis (DLSO) in non-specialized clinical environments, as well as recommendations for patient referral 4.
- The project suggests that DLSO diagnosis is predominantly based on clinical aspects, and microscopy and fungal culture are commonly employed to establish the diagnosis, and that assessment of clinical features is the main method for DLSO follow-up 4.
- The main criterion to define cure is a combination of mycologic cure and clinical cure, and the most commonly selected treatments for onychomycosis include oral antifungals, topical antifungals, and nail debridement 4.