What is the management approach for an infected ingrown toenail?

Management of Infected Ingrown Toenail

For infected ingrown toenails, treatment should include warm antiseptic soaks, topical povidone-iodine, appropriate oral antibiotics, and consideration of partial nail avulsion for severe 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 secondary bacterial or mycological superinfections, which are present in up to 25% of cases 3

Conservative Management (Mild Cases)

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

Antimicrobial Therapy (For Infection)

• For infected ingrown toenails, oral antibiotics should be selected based on likely pathogens 1, 2
• Start with cephalexin as first-line therapy for coverage against Staphylococcus aureus and other gram-positive organisms 1, 2
• If initial treatment fails, consider switching to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 1
• Obtain bacterial cultures if pus is present to guide antibiotic selection 2
• Apply topical antibiotics such as bacitracin 1-3 times daily to the affected area 6

Management of Granulation Tissue

• For pyogenic granuloma formation, consider scoop shave removal with hyfrecation 1, 2
• Silver nitrate application is effective for chemical cauterization of excessive granulation tissue 1, 2, 7
• For recurrent, severe, or treatment-refractory cases, consider intralesional triamcinolone acetonide 1
• Topical timolol 0.5% gel twice daily under occlusion has shown benefit in some cases 1

Surgical Intervention (For Moderate to Severe Cases)

• Partial nail avulsion is indicated for persistent pain, drainage beyond 2-4 weeks, or failure of conservative management 2, 5
• Partial nail avulsion combined with phenolization (chemical matricectomy) is more effective at preventing recurrence than surgical excision alone 5, 4
• Alternative surgical options include electrocautery, radiofrequency, and carbon dioxide laser ablation of the nail matrix 5, 8
• Note that oral antibiotics before or after phenolization do not improve outcomes 5

Prevention of Recurrence

• Proper nail trimming technique: cut nails straight across, not too short 1, 2
• Avoid repeated friction, trauma, and excessive pressure 1, 2
• Wear comfortable well-fitting shoes and cotton socks 1, 2
• Use protective gloves during activities involving water or chemicals 1, 2
• Regular application of emollients to cuticles and periungual tissues 1, 2
• Maintain good foot hygiene to prevent recurrent infections 5, 4

Follow-up

• Reassess after 2 weeks of treatment 1, 2
• If no improvement is seen, consider referral to dermatology or podiatry for further evaluation 1, 2
• Monitor for signs of infection including increased pain, redness, swelling, or purulent drainage 2