What is the treatment for an ingrown toenail infection?

Treatment of Ingrown Toenail Infection

For an infected ingrown toenail, treatment should include topical antibiotics combined with conservative management for mild cases, while moderate to severe cases require partial nail avulsion with or without matricectomy.

Initial Assessment and Classification

When evaluating an infected ingrown toenail, first determine the severity:

• Stage 1 (Mild): Erythema, slight swelling, and tenderness along the nail fold
• Stage 2 (Moderate): Increased pain, drainage, and infection
• Stage 3 (Severe): Significant lateral wall hypertrophy and granulation tissue

Treatment Algorithm

For Mild Infections (Stage 1):

1. Conservative management:

   • Warm water soaks with antiseptic solution 3-4 times daily for 15-20 minutes 1
   • Application of topical antibiotics (combined with high-potency topical corticosteroids) 1
   • Cotton wisps or dental floss placed under the ingrown nail edge to separate it from the lateral fold 2
   • Gutter splinting to separate the nail from the lateral fold for immediate pain relief 2

2. Preventive measures (to be implemented immediately):

   • Proper nail trimming technique (straight across, not curved) 3
   • Wearing properly fitting shoes with adequate toe box space 1
   • Avoiding excessive pressure or trauma to the toes 1

For Moderate Infections (Stage 2):

1. Topical treatment:

   • Topical povidone iodine 2% twice daily (shown benefit in controlled studies) 1
   • Consider silver nitrate chemical cauterization for granulation tissue 1

2. Surgical options if conservative treatment fails:

   • Partial nail avulsion of the affected lateral edge 2
   • Consider phenolization of the nail matrix to prevent recurrence 4

For Severe Infections (Stage 3):

1. Surgical intervention:
   • Partial nail avulsion with lateral matricectomy 2, 4
   • Destruction of lateral wall granulation tissue 5
   • Matricectomy can be performed through chemical (phenol), surgical, or electrosurgical means 2

Important Considerations

• Antibiotics: Oral antibiotics are generally not necessary for localized ingrown toenail infections. Research shows no significant difference in healing time between patients treated with a chemical matricectomy alone versus those receiving both matricectomy and oral antibiotics 6.

• Secondary fungal infection: If there is evidence of fungal infection (onychomycosis), consider appropriate antifungal treatment after resolving the acute infection 1.

• Diabetic patients: Require more aggressive management due to increased risk of complications. Early surgical intervention may be warranted 1.

Common Pitfalls to Avoid

1. Improper nail trimming: Cutting the corners of nails too short or rounding them increases risk of recurrence 3.

2. Delayed treatment: What begins as a mild infection can progress to more severe stages requiring surgical intervention if not properly managed early.

3. Overuse of oral antibiotics: Evidence suggests that oral antibiotics do not improve outcomes for localized ingrown toenail infections 6.

4. Inadequate follow-up: Patients should be monitored until complete resolution to prevent recurrence.

5. Failure to address underlying causes: Footwear, nail cutting habits, and hyperhidrosis must be addressed to prevent recurrence 2.

By following this structured approach based on the severity of the infection, most ingrown toenail infections can be effectively managed with minimal complications and reduced risk of recurrence.