What is the treatment for an ingrown toenail with erythema and pain?

Treatment of Ingrown Toenail with Erythema and Pain

For an ingrown toenail with erythema and pain, the treatment should begin with warm soaks with Burow solution or 1% acetic acid for 15-20 minutes, 2-3 times daily, followed by application of high-potency topical corticosteroids with or without topical antibiotics; surgical drainage is mandatory if an abscess is present. 1

Initial Assessment and Classification

The management approach depends on the severity of the ingrown toenail:

• Grade 1 (Mild): Erythema, slight edema, pain with pressure
• Grade 2 (Moderate): Increased erythema, edema, drainage, infection
• Grade 3 (Severe): Significant erythema, severe granulation tissue, marked pain

Conservative Management (for Mild to Moderate Cases)

1. Immediate Pain Relief Measures:

   • Warm soaks with Burow solution or 1% acetic acid for 15-20 minutes, 2-3 times daily 1
   • Application of high-potency topical corticosteroids to reduce inflammation 1
   • Topical antibiotics if signs of infection are present 1

2. Mechanical Interventions:

   • Gently place cotton wisps or dental floss under the ingrown lateral nail edge to separate it from the nail fold 2
   • Consider a gutter splint application to the ingrown nail edge for immediate pain relief 2
   • Cotton nail cast made from cotton and cyanoacrylate adhesive may be used 2

3. Preventive Measures:

   • Correct inappropriate footwear (avoid tight shoes) 2
   • Proper nail trimming technique (straight across, not too short) 1
   • Keep feet dry and clean 1
   • Apply daily topical emollients to cuticles and periungual tissues 1

Surgical Management (for Moderate to Severe Cases)

When conservative measures fail or for more severe cases:

1. Drainage Procedures:

   • If abscess is present, surgical drainage is mandatory 1
   • Options range from using a hypodermic needle to lift the nail fold to a wide incision with a scalpel 1

2. Definitive Surgical Interventions:

   • Partial nail avulsion: Removal of the ingrown lateral edge of the nail plate 2, 3
   • Matrixectomy: Destruction of the nail matrix to prevent regrowth, performed through:
     • Chemical means (phenolization)
     • Surgical excision
     • Electrocautery or radiofrequency ablation 3

3. Post-Surgical Care:

   • Continue warm soaks
   • Monitor for signs of infection
   • Follow-up within 1-2 weeks to ensure proper healing 1

Special Considerations

• Diabetic patients: Require more vigilant monitoring and earlier intervention due to increased risk of infection 1
• Immunocompromised patients: Should be especially cautious about infection risk 1
• Fungal involvement: If onychomycosis is present, antifungal treatment may be necessary 4, 1

When to Seek Further Medical Evaluation

Return for medical evaluation within 48-72 hours if:

• Signs of spreading infection develop
• Systemic symptoms appear (fever, chills)
• No improvement with initial treatment
• Abscess formation occurs 1

Complications to Monitor

• Permanent nail deformity
• Secondary bacterial or fungal infections (up to 25% of cases)
• Permanent onycholysis 1

The evidence strongly supports that surgical approaches are superior to nonsurgical ones for preventing recurrence, with partial nail avulsion followed by phenolization being particularly effective 3.