What is the treatment for an ingrown toenail?

Treatment for Ingrown Toenail

The treatment for ingrown toenail should follow a staged approach based on severity, with conservative measures for mild cases and surgical intervention for severe or recurrent cases.

Initial Conservative Management

For mild to moderate ingrown toenails:

• Warm soaks: Soak the affected foot in warm, soapy water or dilute vinegar soaks (50:50 dilution) for 10-15 minutes twice daily 1
• Proper nail trimming: Cut toenails straight across, not too short, to prevent recurrence 1
• Cotton packing: Insert cotton wisps or dental floss under the ingrown nail edge to separate it from the nail fold 1, 2
• Taping technique: Tape the nail fold away from the nail plate to reduce pressure 1
• Topical treatments:
  • Apply topical 2% povidone-iodine to prevent infection 1
  • Mid to high potency topical steroid ointment to nail folds twice daily for inflammation 1

For Moderate Cases with Inflammation

When there is pain, edema, or early infection:

• Antimicrobial therapy: If infection is suspected, obtain cultures and treat with appropriate antibiotics 1
• Gutter splinting: Place a flexible tube with a lengthwise incision on the lateral edge of the nail 1, 2
• Dental floss technique: Insert dental floss under the ingrown nail to separate the lateral nail edge from underlying tissue 1

For Severe or Recurrent Cases

Surgical intervention is indicated for:

• Persistent pain despite conservative treatment
• Recurrent ingrown toenails
• Presence of granulation tissue
• Significant infection

Surgical Options:

1. Partial nail avulsion with phenolization:

   • Most effective procedure for preventing recurrence 2
   • Involves removing the ingrown portion of nail and applying phenol to destroy the nail matrix 2, 3

2. Partial nail avulsion without matricectomy:

   • Removes large volume of soft tissue surrounding the nail plate 4
   • Preserves nail matrix for better cosmetic results 4

3. Surgical excision of granulation tissue:

   • For cases with significant granulation tissue, scoop shave removal with silver nitrate application 1

Special Considerations

• For diabetic patients: More aggressive treatment is warranted due to higher risk of complications. Provide appropriate treatment for ingrown toenails promptly to prevent foot ulcers 1

• For cases with pyogenic granulomas: Consider topical timolol 0.5% gel twice daily under occlusion or high-potency topical steroids 1

• For recurrent, severe cases: Consider intralesional triamcinolone acetonide injection 1

Prevention Strategies

• Educate patients on proper nail trimming techniques (straight across, not too short) 1
• Recommend wearing comfortable, well-fitting shoes with adequate toe box space 1
• Avoid trauma to the toenails and excessive pressure 1
• Daily foot hygiene with gentle washing and thorough drying, particularly between toes 1

Common Pitfalls to Avoid

1. Cutting nails too short or rounding the corners, which promotes ingrowth
2. Using topical steroids when infection is present
3. Delaying surgical intervention for severe or recurrent cases
4. Failing to address underlying contributing factors (improper footwear, hyperhidrosis)
5. Inadequate follow-up after treatment to ensure proper healing and prevent recurrence

By following this algorithmic approach based on severity, most ingrown toenails can be effectively treated with minimal complications and reduced risk of recurrence.