What is the treatment for ingrown toenails?

Management of Ingrown Toenails

Ingrown toenails should be treated with appropriate interventions based on severity, ranging from conservative measures for mild cases to surgical interventions for severe or recurrent cases. 1, 2

Classification and Assessment

Ingrown toenails can be classified by severity:

• Mild (Stage 1): Nail fold erythema, mild swelling, and pain
• Moderate (Stage 2): Increased erythema, swelling, pain, and possible discharge
• Severe (Stage 3): Significant inflammation, granulation tissue, and infection

Treatment Algorithm

Conservative Management (Mild to Moderate Cases)

1. Initial measures:

   • Proper nail trimming (straight across, not too short)
   • Comfortable, properly fitting footwear with adequate toe box
   • Warm water soaks with Epsom salts
   • Cotton wisps or dental floss placed under the ingrown nail edge to separate it from the lateral fold 2, 3
   • Gutter splint application for immediate pain relief 3

2. Topical treatments:

   • For inflammation: Mid to high-potency topical corticosteroids 2
   • For infection risk: Topical povidone iodine 2% or topical antibiotics 1

Surgical Management (Moderate to Severe Cases)

1. Partial nail avulsion:

   • Remove the offending portion of the nail
   • Most common surgical approach for ingrown toenails 3

2. Matrixectomy options:

   • Chemical (phenolization) - most effective for preventing recurrence 2, 4
   • Surgical excision of nail matrix
   • Electrocautery or radiofrequency ablation 2

3. Post-surgical care:

   • Topical antibiotics if indicated
   • Regular dressing changes
   • Elevation and limited weight-bearing initially

Special Considerations

Diabetic Patients

• Early intervention is crucial to prevent complications
• Provide appropriate treatment for any pre-ulcerative lesion or ingrown toenail to prevent foot ulcers 1
• Consider early referral to foot care specialists for moderate to severe cases 2
• Avoid surgical procedures in patients with poor circulation without prior vascular evaluation 2

Recurrent Ingrown Toenails

• Partial nail avulsion followed by phenolization is superior to prevent recurrence 2, 4
• According to the most recent evidence, this approach is more effective than surgical excision without phenolization 4

Prevention Strategies

• Trim nails straight across, not too short or rounded at corners
• Wear properly fitting shoes with adequate toe box
• Apply daily emollients to cuticles and periungual tissues 2
• Avoid trauma and excessive pressure to the toes
• Manage contributing conditions like hyperhidrosis and onychomycosis 3

Common Pitfalls to Avoid

1. Improper nail trimming - cutting too short or rounding corners increases risk
2. Delayed treatment - can lead to infection, abscess formation, and permanent nail deformity
3. Inadequate follow-up - especially important in diabetic patients
4. Overlooking contributing factors - footwear, hygiene, hyperhidrosis
5. Inappropriate antibiotic use - oral antibiotics before or after phenolization do not improve outcomes 4

By following this structured approach to ingrown toenail management, clinicians can effectively treat this common condition while minimizing complications and recurrence.