What is the best treatment for an ingrown toenail?

Ingrown Toenail Management

Partial nail avulsion followed by phenolization is the most effective treatment for moderate to severe ingrown toenails, while conservative measures are appropriate for mild cases. 1

Classification and Treatment Approach

Treatment should be tailored based on severity:

Mild Cases (nail fold erythema, mild swelling, pain)

• Conservative management:
  • Warm, soapy water soaks
  • Cotton wisps or dental floss placed under the ingrown nail edge 2
  • Topical corticosteroids to reduce inflammation 1
  • Gutter splinting to separate nail from lateral fold for immediate pain relief 3

Moderate to Severe Cases (increased erythema, swelling, discharge, granulation tissue)

• Surgical intervention:
  • Partial nail avulsion (removal of the offending portion of nail) 1, 2
  • Matrixectomy to prevent recurrence:
    • Chemical (phenolization) - most effective option
    • Surgical excision of nail matrix
    • Electrocautery or radiofrequency ablation 1

Procedural Details

Partial Nail Avulsion with Phenolization

1. Administer digital nerve block
2. Remove the ingrown portion of the nail
3. Apply phenol to the exposed nail matrix (prevents regrowth)
4. Dress the wound appropriately

This combined approach has been shown to be superior to surgical excision alone in preventing recurrence, though it carries a slightly increased risk of postoperative infection 2.

Post-Surgical Care

• Topical antibiotics if indicated
• Regular dressing changes
• Initial elevation and limited weight-bearing 1
• Monitor for signs of infection

Special Considerations

Infection Management

• Topical povidone iodine 2% or topical antibiotics for mild infections 1
• Oral antibiotics may be necessary for more severe infections, though they do not improve outcomes when used prophylactically before or after phenolization 2

Diabetic Patients

• Require more frequent evaluation
• Early referral to foot care specialists
• Avoid surgical procedures in patients with poor circulation without prior vascular evaluation 1

Prevention Strategies

To prevent recurrence:

• 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
• Manage contributing conditions like hyperhidrosis and onychomycosis 1, 3

Common Pitfalls

1. Inappropriate nail trimming technique - rounding corners increases risk of ingrowth
2. Delayed treatment - can lead to severe infection, even gangrene in rare cases 4
3. Inadequate matrix destruction - leads to recurrence when performing partial avulsion
4. Overlooking underlying conditions - hyperhidrosis and onychomycosis can contribute to recurrence
5. Improper footwear - tight shoes can exacerbate the condition 3

The evidence strongly supports that for long-term resolution of moderate to severe ingrown toenails, partial nail avulsion with phenolization provides the best outcomes with the lowest recurrence rates 1, 2, 3.