What is the treatment for an infected ingrown toenail?

Treatment of Infected Ingrown Toenail

The treatment of an infected ingrown toenail requires both antimicrobial therapy and surgical intervention, with topical povidone iodine 2%, topical antibiotics/corticosteroids for mild cases, and oral antibiotics plus partial nail avulsion for moderate to severe cases. 1

Assessment of Severity

Infected ingrown toenails can be classified based on severity:

• Grade 1: Nail fold edema or erythema with disruption of the cuticle
• Grade 2: Nail fold edema or erythema with pain, discharge, or nail plate separation
• Grade 3: Severe infection limiting self-care activities 1

Treatment Algorithm

For Mild Infection (Grade 1)

1. Conservative management:

   • Topical povidone iodine 2% application 1
   • Topical antibiotics combined with corticosteroids 1
   • Warm, soapy water soaks 3-4 times daily 2
   • Cotton wisp or dental floss placement under the ingrown nail edge 3
   • Proper nail trimming education (straight across, not too short) 4

2. Reassess after 2 weeks - if worsening or not improving, proceed to next level of treatment 1

For Moderate Infection (Grade 2)

1. Antimicrobial therapy:

   • Topical povidone iodine 2% plus topical antibiotics and corticosteroids 1
   • Oral antibiotics (empiric therapy aimed at aerobic gram-positive cocci for patients without recent antibiotic exposure) 1

2. Mechanical intervention:

   • Gutter splinting to separate nail edge from lateral fold 2
   • Partial nail avulsion of the ingrown lateral edge 2, 3

3. Duration of antibiotics: 1-2 weeks usually suffices for mild to moderate infections 1

For Severe Infection (Grade 3)

1. Interrupt activities until improvement to Grade 0/1 1

2. Aggressive treatment:

   • Obtain bacterial/fungal cultures 1
   • Oral antibiotics (broader spectrum may be needed) 1
   • Partial nail avulsion with or without phenolization 3
   • Consider surgical consultation for deep abscess or extensive involvement 1

3. Duration of antibiotics: 2-4 weeks depending on structures involved, adequacy of debridement, and wound vascularity 1

Important Considerations

• Surgical approaches are superior to nonsurgical ones for preventing recurrence 2
• Partial nail avulsion combined with phenolization is more effective at preventing recurrence than surgical excision alone, though with slightly increased risk of postoperative infection 3
• Preventive measures are crucial to avoid recurrence:
  • Wearing comfortable shoes that don't compress toes 1
  • Avoiding cutting nails too short 1
  • Regular nail trimming ensuring they are straight 1
  • Daily application of emollients to cuticles and periungual tissues 1

Caution and Follow-up

• Rare but serious complications like gangrene can occur, especially with untreated severe infections 5
• Early and careful follow-up is essential to ensure treatment effectiveness 1
• If infection fails to respond to initial antibiotic course, consider discontinuing antimicrobials and obtaining new culture specimens after a few days 1

Special Considerations

• For patients with fungal infection complicating the ingrown toenail, consider adding antifungal treatment:
  • Topical antifungals for mild cases 6
  • Oral terbinafine (250 mg daily for 12-16 weeks) for more severe cases 6

Remember that proper wound care, in addition to appropriate antibiotic treatment, is crucial for healing of infected ingrown toenails 1.