What is the treatment for an infected ingrown toenail?

Treatment of Infected Ingrown Toenail

For infected ingrown toenails, treatment should include topical povidone iodine 2% application, topical antibiotics combined with corticosteroids for mild cases, and oral antibiotics targeting gram-positive cocci for moderate to severe cases, with partial nail avulsion necessary for moderate to severe infections. 1

Classification and Assessment

Infected ingrown toenails can be classified by severity:

• Grade 1: Nail fold edema/erythema with cuticle disruption
• Grade 2: Nail fold edema/erythema with pain, discharge, or nail plate separation
• Grade 3: Severe infection limiting self-care activities

Treatment Algorithm

Conservative Management (Grade 1)

• Daily warm, soapy water soaks (10-15 minutes)
• Topical 2% povidone-iodine application 2, 1
• Mid to high potency topical steroid ointment to nail folds twice daily 2
• Dilute vinegar soaks to nail folds twice daily 2
• Cotton wisps or dental floss placed under the ingrown nail edge 1, 3

Moderate Infection (Grade 2)

• Continue conservative measures above
• Oral antibiotics targeting Staphylococcus aureus and other gram-positive cocci 1
  • 1-2 weeks duration for mild to moderate infections
  • Obtain cultures if infection is suspected 2
• Consider gutter splint application to separate nail from lateral fold 3
• Taping the lateral nail fold away from nail plate 2

Severe Infection (Grade 3)

• Partial nail avulsion of the ingrown lateral edge 1
• Oral antibiotics for 2-4 weeks depending on structures involved 1
• Consider complete removal if recurrent or treatment-refractory 2
• If painful hematoma or subungual abscess is present, partial or total nail avulsion is required 2

Mechanical Interventions

For persistent or recurrent cases:

• Partial nail avulsion: Removal of the ingrown portion of nail
• Matrixectomy: Destruction of the nail matrix to prevent regrowth
  • Chemical (phenol application)
  • Surgical excision
  • Electrosurgical methods 3

Special Considerations

• Diabetic patients: Require prompt and aggressive treatment to prevent complications 2
• Fungal infections: Consider adding antifungal treatment (topical for mild cases, oral for severe) 1
• Recurrent infections: May require permanent partial or complete nail removal with matrixectomy 3

Prevention Measures

• Proper nail trimming technique (straight across, not too short) 2
• Appropriate footwear that doesn't compress toes 1
• Daily application of emollients to cuticles and periungual tissues 2, 1
• Regular foot inspection, especially for diabetic patients 2

Follow-up Care

• Early follow-up to ensure treatment effectiveness
• If infection fails to respond to initial antibiotics, discontinue antimicrobials and obtain new culture specimens 1
• Monitor for rare but serious complications like gangrene in high-risk patients

Common Pitfalls to Avoid

• Cutting nails too short or rounding the corners (increases risk of ingrowth)
• Delaying treatment, especially in diabetic patients
• Inadequate antibiotic course duration
• Failure to address underlying causes (improper footwear, nail cutting technique)
• Not providing patient education on prevention

Proper treatment of infected ingrown toenails requires addressing both the infection and the mechanical factors causing the ingrowth. Early intervention can prevent complications and reduce the need for more invasive procedures.