What is the first-line treatment for a purulent ingrown toenail?

First-Line Treatment for Purulent Ingrown Toenail

The first-line treatment for a purulent ingrown toenail includes warm antiseptic soaks with dilute povidone-iodine 2% solution twice daily, combined with topical antibiotics and corticosteroids, followed by partial nail avulsion if conservative measures fail. 1

Initial Conservative Management

• Begin with warm antiseptic soaks using 2% povidone-iodine solution or dilute vinegar (50:50 dilution) for 10-15 minutes twice daily to reduce bacterial load and inflammation 2, 1
• Apply mid to high-potency topical steroid ointment to the nail folds twice daily to reduce inflammation 2, 1
• Obtain bacterial cultures if there is significant purulence or signs of spreading infection 2
• Avoid manipulation of the cuticles and trauma to the affected area 2
• Consider cotton packing or dental floss insertion under the ingrown nail edge to separate the lateral nail edge from the underlying tissue 2, 3

Mechanical Interventions

• For mild to moderate cases, implement gutter splinting with a flexible tube placed on the lateral edge of the nail to encapsulate it and prevent further ingrowth 2, 4
• Consider taping the lateral nail fold away from the nail plate to reduce pressure and pain 2
• For moderate cases with significant onychocryptosis (ingrown nail), dental floss nail technique or cotton packing under the ingrown edge can provide immediate relief 3, 4

Pharmacological Management

• For cases with signs of infection, combine topical therapy with oral antibiotics active against common skin pathogens (streptococci and Staphylococcus aureus) 2
• The recommended duration of antimicrobial therapy is 5 days, extending treatment if infection has not improved within this period 2
• For recurrent, severe, or treatment-refractory cases, consider doxycycline 100 mg twice daily with follow-up after one month 2

Surgical Management

• If conservative measures fail or there is significant infection, partial nail avulsion of the ingrown portion should be performed 3, 4
• For severe or recurrent cases, partial nail avulsion combined with phenolization (chemical matricectomy) is more effective at preventing symptomatic recurrence than surgical excision alone 3
• For purulent granulation tissue, perform scoop shave removal followed by silver nitrate application or hyfrecation 2

Special Considerations

• Identify and treat predisposing factors such as improper nail trimming, tight footwear, hyperhidrosis, or underlying nail disorders 4
• For patients with diabetes or immunocompromised status, have a lower threshold for oral antibiotics and surgical intervention 2
• Carefully examine interdigital toe spaces for fissuring, scaling, or maceration, as treating these conditions may reduce recurrent infection 2

Prevention of Recurrence

• Educate patients on proper nail trimming techniques (straight across, not too short) 2, 1
• Recommend wearing comfortable, well-fitting shoes with adequate toe box space 2, 1
• Apply emollients to periungual tissues regularly 2, 1
• Consider prophylactic measures for patients with frequent recurrences 2

The evidence strongly supports a stepwise approach starting with conservative measures for mild cases and progressing to surgical interventions for severe or refractory cases. Phenolization after partial nail avulsion has been shown to be particularly effective at preventing recurrence, though it carries a slightly increased risk of postoperative infection 3.