Management of Ingrown Toenails: Surgical vs. Non-surgical Approaches
Surgical intervention is recommended for ingrown toenails as it is more effective than non-surgical approaches in preventing recurrence, with partial nail avulsion combined with phenolization being the most effective treatment option. 1
Treatment Options Based on Severity
Mild to Moderate Cases
- Conservative (non-surgical) treatments are typically used for mild to moderate ingrown toenails 2:
- Correcting inappropriate footwear that may contribute to the condition 2
- Managing associated conditions like hyperhidrosis and onychomycosis 2
- Soaking the affected toe followed by applying a mid- to high-potency topical steroid 2
- Placing cotton wisps or dental floss under the ingrown lateral nail edge 2, 3
- Application of gutter splints to separate the ingrown nail edge from the lateral fold 2
- Cotton nail cast made from cotton and cyanoacrylate adhesive 2
- Taping the lateral nail fold or using orthonyxia (nail braces) 2, 4
Moderate to Severe Cases
- Surgical approaches are superior to non-surgical methods for preventing recurrence 1:
- Partial nail avulsion (removal of the ingrown portion of the nail) 3
- Partial nail avulsion combined with phenolization (chemical destruction of the nail matrix) 3, 5
- Complete nail excision with or without phenolization 3
- Matrix destruction techniques: phenolization, electrocautery, radiofrequency, or carbon dioxide laser ablation 3
Evidence for Surgical Approach
- Surgical interventions are more effective than non-surgical interventions in preventing recurrence of ingrown toenails 1
- Partial nail avulsion combined with phenolization has been shown to be the safest, simplest method with the lowest recurrence rate 4
- In a study of 117 participants, surgical intervention with phenol was significantly more effective in preventing recurrence than surgical intervention alone (14% vs 41% recurrence rate) 1
- Wedge excisions are no longer recommended due to higher recurrence rates 4
Special Considerations for Diabetic Patients
- For diabetic patients at risk of foot ulceration, appropriate treatment of ingrown toenails is strongly recommended to prevent foot ulcers 6
- In diabetic patients with non-rigid hammertoe and nail changes or pre-ulcerative lesions, digital flexor tendon tenotomy may be considered to help prevent foot ulcers 6
- Treatment of ingrown toenails in diabetic patients should be performed by an appropriately trained healthcare professional 6
Important Clinical Considerations
- Mycological confirmation should be obtained before starting any treatment for suspected fungal nail infections 6
- Oral antibiotics before or after phenolization do not improve outcomes 3
- Postoperative interventions (antibiotics, manuka honey, povidone-iodine, hydrogel) have not shown significant differences in infection rates, pain, or healing time 1
- For treatment failures, consider factors such as poor compliance, poor absorption of medications, immunosuppression, or presence of a subungual dermatophytoma 6
Prevention of Recurrence
- Educate patients about proper nail trimming techniques (cutting straight across) 6
- Recommend appropriate footwear that accommodates the shape of the feet 6
- For patients with recurrent issues, consider preventive measures such as regular professional nail care 6
- In cases of fungal involvement, treat the underlying infection to prevent recurrence 6