What antibiotics are used to treat an ingrown toenail?

Antibiotic Treatment for Ingrown Toenails

For infected ingrown toenails, oral antibiotics are usually not necessary if adequate drainage is achieved, except in immunocompromised patients or severe infections. When antibiotics are needed, they should target common skin flora including Staphylococcus aureus and Streptococcus species. 1

Assessment of Infection Severity

Infected ingrown toenails (acute paronychia) can be categorized into three grades:

1. Grade 1 (Mild): Local inflammation without purulence

   • Treatment: Conservative management without antibiotics

2. Grade 2 (Moderate): Localized infection with purulence

   • Treatment: Drainage plus possible antibiotics

3. Grade 3 (Severe): Spreading infection or systemic symptoms

   • Treatment: Drainage plus antibiotics required

Antibiotic Selection

When antibiotics are indicated for infected ingrown toenails:

First-line options:

• Cephalexin (500 mg four times daily for 7-10 days)
• Dicloxacillin (500 mg four times daily for 7-10 days)
• Amoxicillin-clavulanate (875/125 mg twice daily for 7-10 days)

For penicillin-allergic patients:

• Clindamycin (300-450 mg four times daily) 1
• Trimethoprim-sulfamethoxazole (1-2 DS tablets twice daily)

Treatment Algorithm

1. Assess infection severity:

   • Check for abscess formation, cellulitis, lymphangitis, or systemic symptoms
   • Determine if surgical drainage is needed

2. For mild inflammation without abscess:

   • High-potency topical corticosteroids alone or combined with topical antibiotics 1
   • Topical antiseptics such as povidone-iodine 2% twice daily 1
   • Antimicrobial soaks (Epsom salts) for 15-20 minutes, 2-3 times daily 1

3. For moderate to severe infection:

   • Surgical drainage is mandatory for abscesses 1
   • Follow with appropriate oral antibiotic therapy as listed above
   • Consider culture if unusual organisms are suspected or in treatment failure

Important Considerations

• Diabetic patients require more vigilant monitoring due to increased risk of complications 1
• Immunocompromised patients should receive antibiotics at a lower threshold 1
• Secondary fungal superinfections can occur in up to 25% of cases and may require antifungal treatment 1

Prevention of Recurrent Infection

• Daily application of topical emollients to cuticles and periungual tissues
• Regular proper nail trimming (straight across, not too short)
• Avoiding repeated friction, trauma, and excessive pressure
• Wearing appropriate footwear with adequate toe box space 1, 2

Common Pitfalls to Avoid

1. Overuse of antibiotics for mild cases that can be managed with drainage and local care
2. Failure to drain abscesses when present, leading to treatment failure
3. Not addressing underlying causes such as improper nail trimming or tight footwear
4. Missing fungal superinfections that may require specific antifungal therapy 1
5. Inadequate follow-up, especially in high-risk patients (diabetics, immunocompromised)

Remember that oral antibiotics are typically reserved for moderate to severe infections or when there are signs of spreading infection. Most mild cases can be managed with conservative measures and proper drainage techniques.