How to treat an ingrown nail?

Treatment of Ingrown Toenails

The initial treatment for ingrown toenails should focus on conservative measures including warm soaks, cotton wisps under the nail edge, and proper nail trimming, with surgical intervention reserved for moderate to severe cases or when conservative management fails. 1

Severity Assessment

First, determine the severity of the ingrown toenail:

• Mild: Nail edge causing discomfort with minimal erythema
• Moderate: Pain, erythema, edema, and possible drainage
• Severe: Significant pain, pronounced inflammation, infection with purulent drainage, or granulation tissue

Treatment Algorithm

Conservative Management (Mild to Moderate Cases)

1. Warm Soaks:

   • Soak the affected foot in warm, soapy water for 10-15 minutes, 2-3 times daily 1
   • Consider adding antiseptic solutions or Epsom salt 2

2. Separation Techniques:

   • Place cotton wisps or dental floss under the ingrown nail edge to relieve pressure 1, 3
   • Application of a gutter splint to separate the nail edge from the lateral fold provides immediate pain relief 3

3. Topical Treatments:

   • Apply mid- to high-potency topical corticosteroid ointment to reduce inflammation 1
   • Use topical antiseptics to prevent infection 1
   • For paronychia: Daily dilute vinegar soaks (50:50 dilution) to nail folds twice daily 1

4. Proper Nail Care:

   • Trim nails straight across (not curved)
   • File nail surfaces with an emery board after softening in warm water
   • Keep nails short and clean 1

Surgical Interventions (Moderate to Severe Cases)

When conservative measures fail or for more severe cases, surgical options include:

1. Partial Nail Avulsion:

   • Removing the detached or ingrown portion of the nail plate
   • Cleaning the nail bed thoroughly 1

2. Matrixectomy Options:

   • Chemical matrixectomy with phenol (most recommended)
   • Surgical excision of the nail matrix
   • Partial nail avulsion combined with phenolization is more effective than surgical excision alone 1, 4

3. Advanced Techniques (for recurrent or severe cases):

   • Radiofrequency ablation
   • Carbon dioxide laser ablation
   • Specialized procedures like Winograd technique or Vandenbos procedure 5

Special Considerations

• Diabetic patients: Require more vigilant monitoring and earlier intervention due to increased infection risk 1
• Immunocompromised patients: Lower threshold for oral antibiotics and more aggressive treatment 1
• Surgical drainage: Mandatory for abscesses in acute bacterial paronychia 1

Prevention Measures

• Wear shoes with adequate toe box width
• Avoid high heels and pointed shoes
• Apply daily topical emollients to cuticles and periungual tissues
• Keep hands and feet dry, avoiding prolonged water exposure 1

Follow-Up Care

• Regular follow-up every 2-4 weeks until resolution
• Return immediately if signs of infection develop
• Monitor for complications including permanent nail deformity, secondary infection, and permanent onycholysis 1

Common Pitfalls to Avoid

• Improper nail trimming: Cutting nails too short or rounding the corners increases risk of ingrowth
• Delayed treatment: Waiting too long can lead to infection requiring more aggressive intervention
• Inadequate follow-up: Failing to monitor for complications, especially in high-risk patients
• Inappropriate surgical technique: Wedge excisions are no longer recommended due to higher recurrence rates 4

Phenolization of the lateral matrix horn is currently considered the safest, simplest surgical method with the lowest recurrence rate for cases requiring surgical intervention 4.