Medical Management of Ingrown Nails
The medical management of ingrown nails includes daily antiseptic soaks with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily, application of mid to high-potency topical steroid ointment to nail folds twice daily for inflammation, and mechanical separation of the ingrown nail edge from the lateral nail fold using cotton wisps, dental floss, or splinting techniques. 1, 2
Initial Assessment and Conservative Management
- For mild to moderate ingrown nails, begin with nonsurgical approaches including correcting inappropriate footwear, managing contributing factors like hyperhidrosis and onychomycosis, and soaking the affected toe 3
- After soaking, apply a mid to high-potency topical steroid ointment to nail folds twice daily to reduce inflammation 1, 2
- Place cotton wisps or dental floss under the ingrown lateral nail edge to separate the nail from the inflamed tissue 3, 4
- For immediate pain relief, consider applying a gutter splint to the ingrown nail edge to separate it from the lateral fold 3
- A cotton nail cast made from cotton and cyanoacrylate adhesive, taping the lateral nail fold, or orthonyxia may also alleviate mild to moderate ingrown toenail 3
Management of Infection and Inflammation
- If pus is present, obtain cultures and initiate appropriate antibiotics with coverage against Staphylococcus aureus and other gram-positive organisms 2
- Daily dilute vinegar soaks (50:50 dilution) or 2% povidone-iodine to the nail folds twice daily help reduce inflammation and prevent infection 1, 2
- For granulation tissue formation, options include scoop shave removal with hyfrecation or silver nitrate application 5, 2
- For recurrent, severe, or treatment-refractory cases, doxycycline at 100 mg twice daily can be used with recommended follow-up after 1 month 5, 2
Splinting Techniques
- In cases requiring splinting, a plastic tube with a lengthwise incision can be placed on the lateral edge of the nail to encapsulate it 5, 2
- Formable acrylic may be used for fixation of splints and nail prostheses in complex cases 5
- For onychocryptosis (ingrown nail), dental floss insertion under the ingrown nail separates the lateral nail edge from the underlying tissue 5
Prevention of Recurrence
- Regular nail trimming is necessary, ensuring nails are cut straight across and not too short 1, 6
- Daily application of topical emollients to cuticles and periungual tissues to maintain skin barrier function 1
- Avoid repeated trauma to the nail unit by wearing comfortable well-fitting shoes and cotton socks 5, 1
- Wear protective gloves when working with water or chemicals 1
- Avoid cutting cuticles or manipulating the nail folds 1
- Maintain good hand hygiene 1
- Avoid artificial nails and harsh nail products 1
When to Consider Surgical Intervention
- Persistent pain or drainage beyond 2-4 weeks may require surgical intervention 1
- Surgical approaches are superior to nonsurgical ones for preventing recurrence in moderate to severe cases 3
- The most common surgical approach is partial avulsion of the lateral edge of the nail plate 3, 4
- Matrixectomy (through surgical, chemical, or electrosurgical means) further prevents recurrence 3, 7
Post-Procedure Management
- Continue antiseptic soaks if inflammation persists 1
- Reassess wound healing at 2 weeks post-procedure to determine if additional interventions are needed 1
- Monitor for signs of infection including increased pain, redness, swelling, or purulent drainage 2
- Apply a small amount of topical antibiotic (like bacitracin) 1-3 times daily if needed, which may be covered with a sterile bandage 8