What is the treatment for an ingrown toenail infection?

Treatment of Ingrown Toenail Infection

For an infected ingrown toenail, treatment should include both management of the infection and addressing the underlying nail condition through appropriate nonsurgical or surgical interventions based on severity.

Assessment of Severity

• Ingrown toenails can be classified by severity, which guides treatment approach 1:
  • Grade 1: Nail fold edema or erythema with disruption of the cuticle
  • Grade 2: Nail fold edema or erythema with pain, discharge, or nail plate separation
  • Grade 3: Severe inflammation with surgical intervention indicated

Treatment of Infection

Mild Infection (Grade 1)

• Continue monitoring while implementing the following measures:
  • Apply topical povidone iodine 2% or topical antibiotics/corticosteroids 1
  • Soak the foot in warm water with Epsom salt or a combination of Epsom salt with antiseptic solutions 2
  • Reassess after 2 weeks; if worsening, proceed to next level of treatment 1

Moderate Infection (Grade 2)

• Obtain bacterial/viral/fungal cultures if infection is suspected 1
• Apply topical povidone iodine 2% or topical antibiotics with corticosteroids 1
• Consider oral antibiotics if signs of spreading infection are present 1
• Reassess after 2 weeks; if worsening, proceed to next level of treatment 1

Severe Infection (Grade 3)

• Interrupt normal activities until improvement to Grade 0-1 1
• Obtain bacterial/viral/fungal cultures 1
• Implement topical treatments as above AND oral antibiotics 1
• Consider partial nail avulsion to remove the source of infection 1
• Reassess after 2 weeks; if no improvement, surgical intervention is necessary 1

Management of the Ingrown Toenail

Conservative Approaches (for Mild Cases)

• Proper nail care education:
  • Teach correct toenail trimming techniques (straight across, not curved) 3
  • Recommend wearing comfortable, properly fitting shoes 1
  • Avoid excessive pressure and trauma to the toes 1
• Nonsurgical interventions:
  • Place cotton wisps or dental floss under the ingrown nail edge 4
  • Apply a gutter splint to separate the nail from the lateral fold for immediate pain relief 4
  • Consider cotton nail cast made with cyanoacrylate adhesive 4

Surgical Approaches (for Moderate to Severe Cases)

• Partial nail avulsion:
  • Remove the offending portion of the nail causing the ingrowth 5
  • Can be performed with or without matricectomy 5
• Chemical matricectomy:
  • Partial nail avulsion followed by phenolization is more effective at preventing recurrence than surgical excision alone 5
  • Note: Oral antibiotics before or after phenolization do not improve outcomes 5
• Alternative surgical techniques:
  • Radiofrequency ablation of the nail matrix 6
  • Carbon dioxide laser ablation 6
  • Electrocautery 5

Prevention of Recurrence

• Daily application of topical emollients to cuticles and periungual tissues 1
• Management of predisposing factors:
  • Treat hyperhidrosis if present 4
  • Address any underlying onychomycosis 4
  • Use antimicrobial soaks and proper cleansing 1
• Footwear modifications:
  • Wear comfortable shoes with adequate toe box space 1
  • Use absorbent socks to reduce moisture 1
  • Consider antifungal powders in shoes if recurrent infections occur 1

Common Pitfalls and Caveats

• Failure to obtain cultures in moderate to severe infections can lead to ineffective antibiotic treatment 1
• Neglecting to address the underlying cause (improper nail trimming, tight footwear) often leads to recurrence 3
• Partial nail avulsion without matricectomy has higher recurrence rates compared to procedures that include matricectomy 5
• Chemical matricectomy with phenol slightly increases the risk of postoperative infection compared to surgical techniques alone 5
• Treating only the infection without addressing the ingrown nail will result in recurrent infections 4