What is the best course of treatment for a 33-year-old male patient with recurrent left ingrown toenail, onychomycosis (fungal infection of the nail), and overgrowth of the left big toenail, presenting with foot pain?

Management of Recurrent Ingrown Toenail with Onychomycosis

For a 33-year-old male with recurrent left ingrown toenail, onychomycosis, and foot pain, complete nail removal combined with oral antifungal therapy is the most effective treatment approach to prevent recurrence and improve quality of life.

Comprehensive Treatment Plan

1. Surgical Management

• Nail Removal Procedure:
  • Complete removal of the left big toenail as scheduled is appropriate 1
  • This addresses both the ingrown portion and allows treatment of the underlying nail bed affected by fungal infection
  • Partial nail avulsion with phenolization of the nail matrix is recommended to prevent recurrence of the ingrown nail 1

2. Antifungal Treatment

• Oral Antifungal Therapy:
  • Terbinafine 250mg daily for 12 weeks is the first-line treatment for toenail onychomycosis 2
  • Superior efficacy compared to other antifungals for dermatophyte infections with cure rates of 70-80% for toenails 2
  • Low risk of drug interactions makes it preferable, especially if patient is on other medications 2

3. Post-Procedure Care

• Wound Care:

  • Regular soaking in warm, soapy water for the first week post-procedure 3
  • Application of topical antibiotic ointment until healing is complete
  • Keep the area clean and dry between soakings

• Pain Management:

  • Gel insoles as prescribed are appropriate for comfort 4
  • Elevate foot when possible for the first 48-72 hours
  • Over-the-counter pain medication as needed

4. Long-term Management

• Skin Care:

  • Lubriderm as prescribed is appropriate for maintaining skin integrity 4
  • Daily application after bathing to prevent skin dryness and cracking

• Preventive Measures:

  • Patient education on proper nail trimming techniques (straight across, not too short) 5
  • Wearing properly fitted shoes with adequate toe box space
  • Regular foot inspection, especially important to prevent complications 4
  • Use of antifungal powder in shoes to prevent reinfection 2

Important Considerations

Treatment Efficacy

• Surgical removal combined with oral antifungals has higher success rates than either treatment alone for cases with both ingrown nail and onychomycosis 2, 1
• Recurrence rates of 40-70% are common in onychomycosis if comprehensive treatment is not provided 2

Potential Complications

• Watch for:
  • Signs of post-surgical infection (increased pain, redness, discharge)
  • Dermatophytomas (dense white lesions beneath the nail) that may resist treatment 2
  • Incomplete removal of the nail matrix can lead to recurrence of the ingrown nail 1

Follow-up

• Schedule follow-up appointment 2 weeks post-procedure to assess healing
• Monitor for complete resolution of fungal infection over 6-12 months
• Consider prophylactic measures if patient has risk factors for recurrence

Special Considerations

• If diabetic neuropathy is suspected, more aggressive treatment and closer follow-up would be warranted 4
• Ensure proper footwear is worn during recovery to prevent pressure on the affected toe
• Patient should avoid public swimming pools and communal showers until healing is complete to prevent reinfection 2