What are the management options for ingrown toenails?

Management of Ingrown Toenails

For ingrown toenails, treatment should begin with conservative measures for mild cases, progressing to surgical interventions for moderate to severe cases that don't respond to initial management.

Conservative Management (Mild to Moderate Cases)

Immediate Pain Relief Measures

• Warm, soapy water soaks for 10-15 minutes, 2-3 times daily 1
• Apply mid to high-potency topical steroid ointment to nail folds twice daily to reduce inflammation 2, 1
• Placement of cotton wisps, dental floss, or cotton packing under the ingrown nail edge to separate it from the lateral fold 3, 1
• Gutter splinting with flexible tube on lateral edge of nail for immediate pain relief 2, 1

Infection Management

• If signs of infection present (pus, increased pain):
  • Obtain bacterial culture 2
  • Apply topical 2% povidone-iodine twice daily 2
  • Daily dilute vinegar soaks (50:50 dilution) to nail folds twice daily 2
  • For moderate to severe infection: oral antibiotics with anti-staphylococcal coverage 2
  • Apply topical antibiotics like bacitracin or neomycin 1-3 times daily 4, 5

Preventive Measures

• Regular proper nail trimming (straight across, not too short) 2, 3
• Wearing comfortable, well-fitting shoes with adequate toe box 2
• Daily application of topical emollients to cuticles and periungual tissues 2
• Avoiding trauma, excessive pressure, and nail manipulation 2
• Preventive correction of nail curvature with podiatrist referral if needed 2

Surgical Management (Moderate to Severe Cases)

Indications for Surgical Intervention

• Failed conservative management
• Recurrent ingrown toenails
• Severe pain, inflammation, or infection
• Formation of granulation tissue

Surgical Options

1. Partial Nail Avulsion with Phenolization

   • Most effective procedure for preventing recurrence 3, 1
   • Involves removal of lateral nail edge followed by chemical matricectomy 1, 6

2. Alternative Surgical Approaches

   • Partial nail avulsion without phenolization (higher recurrence rate) 3
   • Direct surgical excision of nail matrix 3
   • Electrocautery, radiofrequency, or carbon dioxide laser ablation 3, 6

3. For Pyogenic Granulomas

   • Scoop shave removal with hyfrecation 2
   • Silver nitrate chemical cauterization 2
   • Topical timolol 0.5% gel twice daily under occlusion 2

Special Considerations

Diabetic Patients

• Prompt appropriate treatment for any pre-ulcerative lesions or ingrown toenails to prevent foot ulcers 2
• More vigilant monitoring and earlier intervention recommended 2
• Consider referral to specialized foot care services

Cancer Patients on Targeted Therapy

• Higher risk of paronychia and periungual pyogenic granulomas 2
• May require more aggressive management and monitoring 2
• Consider topical timolol 0.5% gel twice daily under occlusion for treatment 2

Follow-up and Monitoring

• Reassess after 2 weeks for improvement 2
• If no improvement or worsening symptoms, progress to next level of intervention
• Patient education on proper nail care is crucial for preventing recurrence 7

Remember that surgical approaches are superior to nonsurgical ones for preventing recurrence, with partial nail avulsion combined with phenolization being the most effective method 3, 1.