What are the treatment options for an ingrown toenail?

Treatment of Ingrown Toenails

For ingrown toenails, treatment should progress from conservative measures to surgical interventions based on severity, with partial nail avulsion combined with phenolization being the most effective approach for preventing recurrence in severe or recurring cases.

Conservative Management (Mild to Moderate Cases)

Initial Measures

• Warm, soapy water soaks for 15-20 minutes daily 1
• Proper nail trimming technique: cut straight across, not curved 2
• Avoid tight-fitting shoes and wear comfortable footwear with adequate toe room 2
• Placing cotton wisps or dental floss under the ingrown nail edge to separate it from the lateral fold 1, 3
• Application of topical antiseptics such as povidone iodine 2% twice daily 2

Intermediate Interventions

• Gutter splinting to separate the nail from the lateral fold 2, 3
• Cotton nail cast made from cotton and cyanoacrylate adhesive 3
• Taping the lateral nail fold away from the nail plate 2
• Mid to high potency topical steroid ointment to nail folds twice daily for inflammation 2
• Daily dilute vinegar soaks (50:50 dilution) to nail folds twice daily 2

Surgical Management (Moderate to Severe Cases)

Indications for Surgical Intervention

• Persistent pain despite conservative measures
• Recurrent infections
• Significant inflammation or granulation tissue
• Severe onychocryptosis with lateral nail fold hypertrophy

Surgical Options

1. Partial nail avulsion with phenolization (most effective for preventing recurrence) 1

   • Involves removing the ingrown portion of nail and applying phenol to destroy the nail matrix
   • Superior to surgical excision without phenolization for preventing recurrence 1
   • Slightly increased risk of postoperative infection compared to excision alone 1

2. Alternative surgical approaches 4

   • Complete nail excision (Zadik's procedure)
   • Winograd technique (partial matricectomy)
   • Vandenbos procedure (removal of periungual soft tissue)
   • Chemical matricectomy using agents other than phenol

Management of Complications

Infection Management

• If signs of infection present (pus, increased pain, spreading redness):
  • Culture the wound 2
  • Oral antibiotics for moderate to severe infections 2
  • Note: Prophylactic oral antibiotics before or after phenolization do not improve outcomes 1

Granulation Tissue Management

• Silver nitrate application 2
• Scoop shave removal with hyfrecation 2
• High-potency topical steroids 2
• Topical timolol 0.5% gel twice daily under occlusion 2

Special Considerations

Diabetic Patients

• Ingrown toenails represent a pre-ulcerative sign requiring prompt treatment 2
• Treatment should be repeated until the pre-ulcerative sign resolves 2
• Treatment should preferably be performed by a trained foot care specialist 2
• Consider referral to podiatrist for preventive correction of nail curvature 2

Prevention Strategies

• Regular proper nail trimming (straight across, not too short) 2
• Daily application of topical emollients to cuticles and periungual tissues 2
• Wearing comfortable well-fitting shoes and cotton socks 2
• Managing hyperhidrosis if present 3, 5
• Avoiding barefoot walking with insensitive feet (especially in diabetics) 2

Treatment Algorithm Based on Severity

1. Stage 1 (Erythema and mild pain):

   • Conservative measures for 2-4 weeks
   • Progress to surgical options if no improvement

2. Stage 2 (Infection and/or granulation tissue):

   • Conservative measures plus infection management
   • Consider partial nail avulsion if no improvement within 1-2 weeks

3. Stage 3 (Chronic inflammation with hypertrophic lateral nail fold):

   • Partial nail avulsion with phenolization as first-line treatment 1

The evidence strongly supports that partial nail avulsion combined with phenolization is the most effective approach for preventing symptomatic recurrence of ingrown toenails, though it carries a slightly increased risk of postoperative infection 1.