What are the management options for an ingrown toenail?

Management of Ingrown Toenail

The management of ingrown toenail should follow a stepwise approach, beginning with conservative measures for mild cases and progressing to surgical interventions for severe or recurrent cases. 1, 2

Initial Assessment and Classification

• Evaluate severity based on parameters including redness, edema, discharge, and granulation tissue 1
• Check for presence of pus or abscess formation which would require drainage 1
• Assess for predisposing factors such as improper nail trimming, trauma, hyperhidrosis, and poor foot hygiene 2, 3

Conservative Management (First-Line)

For mild to moderate ingrown toenails:

• Implement warm antiseptic soaks with dilute vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes twice daily 1
• Apply topical 2% povidone-iodine twice daily to the affected area 1
• Use mid to high-potency topical steroid ointment to nail folds twice daily to reduce inflammation 1, 4
• Place cotton wisps or dental floss under the ingrown nail edge to separate it from the lateral fold 2, 4
• Consider gutter splinting with a plastic tube placed on the lateral edge of the nail to provide immediate pain relief 5, 4
• Correct inappropriate footwear and manage contributing factors like hyperhidrosis 4

Antimicrobial Therapy

• For infected ingrown toenails, oral antibiotics should be selected based on likely pathogens 1, 6
• Start with cephalexin as first-line therapy 6
• If initial treatment fails, consider switching to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 6
• Be aware that secondary bacterial or mycological superinfections are present in up to 25% of cases 1, 6

Surgical Interventions

For moderate to severe or recurrent ingrown toenails:

• Partial nail avulsion of the lateral edge of the nail plate is the most common surgical approach 2, 4
• Consider matricectomy (destruction of the nail matrix) to prevent recurrence, which can be performed through:
  • Chemical matricectomy with phenol application 7, 2
  • Surgical excision of the nail matrix 2
  • Electrocautery, radiofrequency, or carbon dioxide laser ablation 2, 8
• Partial nail avulsion combined with phenolization is more effective at preventing recurrence than surgical excision alone, but has a slightly increased risk of postoperative infection 2

Special Considerations

• For pyogenic granuloma formation, consider scoop shave removal with hyfrecation or silver nitrate application 5, 1
• For recurrent, severe, or treatment-refractory cases, consider intralesional triamcinolone acetonide 5, 1
• Topical timolol 0.5% gel twice daily under occlusion has shown benefit in some cases 1

Prevention of Recurrence

• Proper nail trimming technique: cut nails straight across, not too short 5, 1
• Avoid repeated friction, trauma, and excessive pressure 5, 1
• Wear comfortable well-fitting shoes and cotton socks 5, 1
• Use protective gloves during activities involving water or chemicals 1, 6
• Regular application of emollients to cuticles and periungual tissues 5, 1

Follow-up

• Reassess after 2 weeks of treatment 1, 6
• If no improvement is seen, consider referral to dermatology or podiatry for further evaluation 1, 6
• For recurrent cases, surgical approaches are superior to nonsurgical ones for preventing recurrence 4

Treatment Algorithm

1. Mild (Stage 1): Conservative measures only (soaks, cotton wisps, proper footwear) 2, 4
2. Moderate (Stage 2): Conservative measures plus antimicrobial therapy if infected; consider gutter splinting 1, 4
3. Severe (Stage 3) or Recurrent: Surgical intervention with partial nail avulsion with or without matricectomy 2, 8, 4