What antibiotics are used to treat infected ingrown toenails?

Antibiotic Treatment for Infected Ingrown Toenails

For infected ingrown toenails, oral antibiotics with anti-staphylococcal and gram-positive coverage are recommended when there are signs of infection, with clindamycin being an appropriate first-line choice for patients with penicillin allergies. 1, 2

Assessment of Infection Severity

Infected ingrown toenails typically present with:

• Nail fold edema or erythema
• Pain
• Discharge or pus
• Granulation tissue formation

Severity can be graded as:

• Grade 1: Nail fold edema/erythema with disruption of the cuticle
• Grade 2: Nail fold edema/erythema with pain, discharge, or nail plate separation
• Grade 3: Severe infection requiring surgical intervention 1

Antibiotic Treatment Algorithm

For Mild Infection (Grade 1):

• Topical antibiotics with corticosteroids
• Topical povidone iodine 2%
• Daily antimicrobial soaks (dilute vinegar or Epsom salt)
• Reassess after 2 weeks 1

For Moderate Infection (Grade 2):

• Obtain bacterial cultures if infection is suspected
• Oral antibiotics with anti-staphylococcal and gram-positive coverage:
  • Dicloxacillin (first-line if no penicillin allergy)
  • Clindamycin (for penicillin-allergic patients)
  • Cefalexin
  • Sulfamethoxazole-trimethoprim (especially if MRSA suspected)
• Continue topical treatments as above 1, 2

For Severe Infection (Grade 3):

• Interrupt any ongoing treatments until infection resolves
• Obtain bacterial cultures
• Oral antibiotics as above
• Consider surgical intervention (partial nail avulsion)
• Reassess after 2 weeks 1

Important Considerations

1. Secondary bacterial infections are present in up to 25% of ingrown toenail cases, with both gram-positive and gram-negative organisms implicated 1

2. Clindamycin is particularly appropriate for penicillin-allergic patients with skin and soft tissue infections caused by susceptible strains of staphylococci and streptococci 2

3. Antibiotic selection should be guided by local resistance patterns and culture results when available 1

4. Evidence suggests that oral antibiotics may not significantly improve healing time when used alongside proper surgical management of the ingrown toenail 3

5. Concurrent treatments should include:

   • Proper nail care (avoiding cutting nails too short)
   • Comfortable shoes to reduce pressure
   • Antimicrobial soaks
   • Topical povidone iodine 2% 1, 4, 5

Pitfalls to Avoid

• Don't delay surgical intervention for severe or persistent infections
• Don't use antibiotics alone without addressing the underlying mechanical issue
• Don't continue antibiotics unnecessarily if surgical management is performed properly, as studies show they may not improve outcomes after proper nail procedure 3
• Don't forget to obtain cultures before starting antibiotics in moderate to severe cases 1

If infection persists despite appropriate antibiotic therapy, consider partial nail avulsion with or without phenolization, as this surgical approach has been shown to be more effective than non-surgical approaches for preventing recurrence 6.