What are the treatment options for an ingrown toenail?

Treatment Options for Ingrown Toenails

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

Classification of Ingrown Toenails

Determine severity to guide treatment approach:

• 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

Conservative Management (Mild to Moderate Cases)

1. Warm Soaks

   • Soak the foot in warm, soapy water for 10-15 minutes, 2-3 times daily 1
   • Daily dilute vinegar soaks (50:50 dilution) to nail folds twice daily can help prevent infection 2, 1

2. Separation Techniques

   • Place cotton wisps or dental floss under the ingrown nail edge to relieve pressure 1, 3
   • Gutter splinting with a plastic tube placed on the lateral edge of the nail 2
   • Cotton nail cast made from cotton and cyanoacrylate adhesive 4

3. Topical Treatments

   • Mid- to high-potency topical corticosteroid ointment for inflammation 2, 1
   • Topical antiseptics to prevent infection 1

4. Proper Nail Care

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

Surgical Management (Moderate to Severe Cases)

1. Partial Nail Avulsion

   • Remove the detached or ingrown portion of the nail plate 1, 4
   • Clean the nail bed thoroughly 1
   • More effective than conservative approaches for preventing recurrence 4

2. Matrixectomy Options

   • Chemical matrixectomy with phenol (most common) 1, 5
   • Surgical excision of the nail matrix 1
   • Partial nail avulsion combined with phenolization is more effective than surgical excision alone for preventing recurrence 3, 6

3. Advanced Techniques (for recurrent or severe cases)

   • Radiofrequency ablation 7
   • Carbon dioxide laser ablation 3, 7
   • Electrocautery of the nail matrix 3

Special Considerations

1. Diabetic Patients

   • Require more vigilant monitoring and earlier intervention due to increased infection risk 1
   • Keep the area dry to prevent further infection 1
   • Lower threshold for oral antibiotics 1

2. Immunocompromised Patients

   • May require more aggressive treatment and closer monitoring 1
   • Consider earlier surgical intervention 1

3. Infection Management

   • Surgical drainage is mandatory for abscesses in acute bacterial paronychia 1
   • Topical antibiotics with steroids for inflammation 1
   • For fungal involvement, topical antifungals (imidazoles) are recommended 1

Prevention Strategies

• Wear shoes with adequate toe box width 1
• Avoid high heels and pointed shoes 1
• Apply daily topical emollients to cuticles and periungual tissues 1
• Avoid prolonged water exposure 1
• Wear gloves while cleaning or doing wet work 1

Follow-up and Monitoring

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

Common Pitfalls and Caveats

1. Oral antibiotics before or after phenolization do not improve outcomes 3
2. Improper nail trimming (curved rather than straight across) can lead to recurrence 1
3. Failure to address underlying causes like improper footwear or hyperhidrosis may result in recurrent ingrown toenails 3, 4
4. Delaying treatment in high-risk patients (diabetics, immunocompromised) can lead to serious complications 1