What is the treatment for an infected ingrown toenail?

Treatment of Infected Ingrown Toenails

For infected ingrown toenails, treatment should include daily warm soapy water soaks, topical 2% povidone-iodine application, and mid to high potency topical steroid ointment to nail folds twice daily for mild cases, with oral antibiotics targeting Staphylococcus aureus and partial nail avulsion required for moderate to severe infections. 1

Treatment Algorithm Based on Severity

Grade 1 (Mild Infection - Nail Fold Edema/Erythema with Cuticle Disruption)

• Daily warm, soapy water soaks (15-20 minutes, 3-4 times daily)
• Topical 2% povidone-iodine application after soaking
• Mid to high potency topical steroid ointment to nail folds twice daily 1
• Cotton wisps or dental floss placement under the ingrown nail edge to separate it from the nail fold 2

Grade 2 (Moderate Infection - Nail Fold Edema/Erythema with Pain, Discharge, or Nail Plate Separation)

• Continue conservative measures as in Grade 1
• Oral antibiotics targeting Staphylococcus aureus and other gram-positive cocci for 1-2 weeks 1
• Partial nail avulsion of the ingrown lateral edge under local anesthesia 1
• Gutter splint application to separate the ingrown nail edge from the lateral fold for immediate pain relief 2

Grade 3 (Severe Infection - Limiting Self-Care Activities)

• Oral antibiotics for 2-4 weeks 1
• Partial or complete nail removal with consideration of matrixectomy to prevent recurrence 1
• Close monitoring, especially in high-risk patients (diabetics, immunocompromised) 1

Antibiotic Selection

• First-line: Cephalexin or dicloxacillin (effective against S. aureus)
• Alternative: Clindamycin or trimethoprim-sulfamethoxazole (for penicillin-allergic patients)
• Duration: 1-2 weeks for mild to moderate infections, 2-4 weeks for severe cases 1

Special Considerations

Diabetic Patients

• Require more aggressive treatment with prompt intervention
• Lower threshold for oral antibiotics and surgical intervention
• Longer duration of antibiotic therapy may be necessary 1
• Close monitoring for complications like gangrene

Concurrent Fungal Infection

• If fungal infection is present, additional antifungal treatment is required
• Terbinafine is superior to itraconazole for dermatophyte infections 3
• For mild cases, topical antifungals may be sufficient
• For more severe fungal infections, oral terbinafine is recommended 3, 1

Surgical Techniques

• Partial nail avulsion followed by phenolization is more effective at preventing recurrence than surgical excision alone 4
• Matrixectomy (chemical, surgical, or electrosurgical) prevents regrowth of the problematic portion of the nail 2
• Surgical approaches are superior to nonsurgical ones for preventing recurrence 2

Prevention and Patient Education

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

Follow-up

• Early follow-up (within 48-72 hours) for moderate to severe infections
• If infection fails to respond to initial antibiotics, discontinue antimicrobials and obtain new culture specimens
• Consider permanent partial or complete nail removal with matrixectomy for recurrent infections 1

Common Pitfalls to Avoid

• Delaying treatment in diabetic patients or those with vascular compromise
• Inadequate removal of the ingrown portion of the nail
• Failure to address underlying causes (improper footwear, incorrect nail trimming)
• Inappropriate antibiotic selection or duration
• Neglecting to provide prevention education to reduce recurrence risk

The treatment approach should be guided by the severity of infection, with conservative measures sufficient for mild cases and more invasive interventions necessary for moderate to severe infections. Proper follow-up and preventive education are essential components of comprehensive management.