What is the recommended treatment for a 25-year-old male patient with a right big ingrown toenail?

Management of Ingrown Toenail in a 25-Year-Old Male

For a 25-year-old male with a right big ingrown toenail, partial nail avulsion with phenolization is recommended as the most effective treatment to prevent recurrence and improve quality of life. 1

Assessment of Severity

Ingrown toenails are classified into three grades:

• Grade 1 (Mild): Nail fold swelling, erythema, and pain with pressure
• Grade 2 (Moderate): Increased swelling, drainage, infection, and ulceration of the nail fold
• Grade 3 (Severe): Chronic inflammation, granulation tissue, and marked nail-fold hypertrophy

Treatment Algorithm

Conservative Management (for Grade 1)

• Appropriate for early or mild cases only
• Warm water soaks with 1% acetic acid for 15-20 minutes, 2-3 times daily 1
• Placing cotton wisps or dental floss under the ingrown lateral nail edge 2
• Gutter splint application to separate nail from lateral fold 2
• Correcting inappropriate footwear and managing hyperhidrosis if present 2

Surgical Management (for Grade 2-3)

• Partial nail avulsion with phenolization - most effective for preventing recurrence 1, 3

  • Procedure involves removing the ingrown portion of the nail and applying phenol to destroy the nail matrix
  • Provides superior outcomes compared to non-surgical approaches 3
  • Lower recurrence rates than partial avulsion without phenolization

• Alternative surgical options:

  • Partial nail avulsion without phenolization (higher recurrence rate) 3
  • Complete nail excision (more invasive, rarely necessary) 3
  • Soft tissue excision without matricectomy (preserves nail anatomy but less evidence for effectiveness) 4

Special Considerations

• Check for fungal infection: If onychomycosis is present, antifungal treatment may be necessary 5, 1

  • Terbinafine 250 mg daily for 12-16 weeks is preferred for dermatophyte infections 5
  • Itraconazole is an alternative (200 mg daily for 12 weeks or pulse therapy) 5

• Post-procedure care:

  • Apply topical antibiotics if signs of infection are present
  • Recommend follow-up within 1-2 weeks to ensure proper healing 1
  • Patient should return within 48-72 hours if signs of infection develop 1

Prevention of Recurrence

• Proper nail trimming technique - straight across, not too short 1
• Appropriate footwear with adequate toe box space 2
• Maintaining good foot hygiene 1
• Avoiding repetitive trauma to the nail 3

Common Pitfalls

• Inadequate treatment: Conservative measures alone have higher recurrence rates in moderate to severe cases 3
• Overlooking infection: Up to 25% of ingrown toenail cases develop secondary bacterial or fungal infections 1
• Improper surgical technique: Incomplete removal of the lateral nail matrix can lead to recurrence 6
• Neglecting post-procedure care: Proper wound care is essential to prevent infection and ensure optimal healing 1

Surgical intervention with partial nail avulsion and phenolization provides the best long-term outcomes for most patients with moderate to severe ingrown toenails, with studies showing lower recurrence rates compared to conservative management or surgical approaches without phenolization 1, 3.