What are the symptoms and management options for ingrown toenails?

Ingrown Toenail Symptoms and Management

The American Academy of Dermatology recommends classifying ingrown toenails into three grades of severity (mild, moderate, and severe), with treatment approaches tailored to each grade, ranging from conservative measures for mild cases to surgical interventions for severe cases. 1

Symptoms and Classification

Ingrown toenails (onychocryptosis) most commonly affect the great toe and present with:

• Grade 1 (Mild): Pain, erythema, and swelling without infection
• Grade 2 (Moderate): Increased pain, erythema, swelling with infection and drainage
• Grade 3 (Severe): Severe pain, chronic inflammation, granulation tissue, and recurrent infection 1, 2

Management Approach

Conservative Management (Grade 1)

For mild cases, non-surgical approaches include:

• Warm soaks with Epsom salt or 1% acetic acid for 15-20 minutes, 2-3 times daily 1, 3
• Placing cotton wisps or dental floss under the ingrown nail edge to separate it from the lateral fold 4, 5
• Gutter splinting to provide immediate pain relief 5
• Correcting improper footwear and managing contributing factors like hyperhidrosis 5
• Application of mid- to high-potency topical steroids after soaking 5

Moderate Cases (Grade 2)

When conservative measures fail or for moderate cases:

• Topical antibiotics with or without topical steroids for inflammation without abscess 1
• Partial nail avulsion (removing the ingrown portion of the nail) 4, 5
• Consider chemical matricectomy with phenol to prevent recurrence 4

Severe Cases (Grade 3)

For severe or recurrent cases:

• Surgical drainage if an abscess is present 1
• Partial nail avulsion combined with phenolization (most effective at preventing recurrence) 4
• Complete nail excision in severe cases 4, 2
• Alternative techniques include radiofrequency ablation, carbon dioxide laser ablation, or electrocautery of the nail matrix 4, 2

Special Considerations

• Diabetic patients: Require more vigilant monitoring and earlier intervention due to increased infection risk 1
• Immunocompromised patients: Need special caution regarding infection risk; may require oral antibiotics even with adequate drainage 1
• Fungal involvement: May require additional antifungal treatment 1

Complications

• Secondary bacterial or fungal infections (up to 25% of cases) 1
• Permanent nail deformity and onycholysis 1
• Recurrence, especially without proper preventive measures 4

Prevention

• Proper nail trimming technique: straight across, not too short 1
• Avoiding tight footwear and repetitive trauma 5
• Managing hyperhidrosis and maintaining good foot hygiene 5
• Regular application of emollients to cuticles and periungual tissues 1

Follow-up

• Follow-up within 1-2 weeks to ensure proper healing 1
• Return within 48-72 hours if signs of infection develop 1
• Seek medical evaluation for abscess formation, spreading infection, systemic symptoms, or failure to improve with home treatment 1

Common Pitfalls

• Improper nail trimming (cutting corners) often leads to recurrence 6
• Oral antibiotics are usually unnecessary if adequate drainage is achieved 1
• Neglecting underlying conditions (hyperhidrosis, improper footwear) can lead to treatment failure 5
• Partial treatments without addressing the nail matrix often result in recurrence 4