What is the recommended treatment for ingrown toenail removal?

Treatment of Ingrown Toenails

The most effective treatment for ingrown toenails is partial nail avulsion combined with phenolization, which is superior to surgical excision without phenolization for preventing symptomatic recurrence. 1

Initial Assessment and Conservative Management

For mild to moderate ingrown toenails without abscess formation, conservative treatment should be attempted first:

• Warm soaks in soapy water
• Placing cotton wisps or dental floss under the ingrown nail edge
• Application of topical povidone-iodine 2% twice daily
• Avoiding trauma to the affected area 2
• Correcting inappropriate footwear
• Managing contributing factors like hyperhidrosis and onychomycosis 1

For moderate cases, additional non-surgical options include:

• Gutter splinting to separate the nail from the lateral fold
• Cotton nail cast made from cotton and cyanoacrylate adhesive
• Taping the lateral nail fold 1

Surgical Management

Surgical intervention is indicated for:

• Moderate to severe cases
• Failed conservative treatment
• Presence of abscess
• Recurrent ingrown toenails

Recommended Surgical Approaches:

1. Partial nail avulsion with phenolization - This is the gold standard treatment with the lowest recurrence rate 1

   • Involves removing the lateral portion of the nail
   • Chemical matrixectomy with phenol prevents regrowth
   • Provides better long-term outcomes than surgical excision alone

2. Partial nail avulsion with direct surgical excision of the nail matrix - Equally effective alternative to phenolization 3

3. Complete nail excision - Reserved for severe cases or when the entire nail is affected 3

Important Surgical Considerations:

• Surgical approaches that remove the interaction between the nail plate and nail fold are superior to non-surgical approaches for preventing recurrence 1
• Compared with surgical excision without phenolization, partial nail avulsion with phenolization has a slightly increased risk of postoperative infection but significantly lower recurrence rates 3
• Oral antibiotics before or after phenolization do not improve outcomes 3

Post-Treatment Care

• Clean the area daily with lukewarm water
• Avoid footbaths that can induce skin maceration
• Keep the wound clean and dry
• Limit standing and walking for the first few days
• Gradually increase activity as pain and swelling decrease 2
• Return for follow-up within 1-2 weeks to ensure proper healing 2

Prevention of Recurrence

Patient education is crucial to prevent recurrence:

• Proper nail trimming technique (straight across, not too short)
• Wearing properly fitting shoes with adequate toe box
• Avoiding repeated friction, trauma, and excessive pressure
• Wearing protective footwear when necessary
• Regular application of emollients to cuticles and periungual tissues 2

Special Considerations

• Diabetic patients: Require more vigilant monitoring and earlier intervention due to increased infection risk 2
• Fungal involvement: Consider combination of broad-spectrum topical antifungal agent with a corticosteroid 2
• Severe inflammation: High-potency topical corticosteroids may be beneficial 2

Common Pitfalls to Avoid

1. Failing to adequately address the nail matrix during surgical treatment, leading to recurrence
2. Overlooking fungal superinfection, which is present in up to 25% of cases 2
3. Improper post-procedure care, increasing risk of infection
4. Inadequate patient education about preventive measures, contributing to high recurrence rates (40-70%) 2