What is the recommended treatment and follow-up for an ingrown toenail with erythema after starting antibiotics?

Management of Ingrown Toenail with Erythema After Antibiotic Treatment

For an ingrown toenail with erythema that has recently been treated with antibiotics, continue topical treatment with povidone iodine 2% and topical antibiotics/corticosteroids while monitoring for improvement over the next two weeks. 1

Assessment of Severity and Treatment Approach

• Evaluate the ingrown toenail based on severity of symptoms, which can be classified as 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: Surgical intervention or antibiotics indicated, limiting self-care activities

• For a patient who has recently started antibiotics, continue monitoring for response to treatment while maintaining appropriate wound care 1

Treatment Algorithm

For Mild Infection (Grade 1) with Recent Antibiotic Treatment:

• Continue current antibiotic course until completed 1
• Apply topical povidone iodine 2% to the affected area daily 1
• Add topical antibiotics/corticosteroids to reduce inflammation 1
• Reassess after 2 weeks; if not improving, proceed to next treatment level 1

For Moderate Infection (Grade 2) with Recent Antibiotic Treatment:

• Continue oral antibiotics with coverage for Staphylococcus aureus and other gram-positive organisms 1
• Apply topical povidone iodine 2% and topical antibiotics/corticosteroids 1
• Consider obtaining bacterial cultures if infection persists despite antibiotics 1
• If discharge or nail plate separation is present, more aggressive treatment may be needed 1

For Severe Infection (Grade 3) or Intolerable Grade 2:

• Consider interrupting any causative medications until condition improves 1
• Continue oral antibiotics with appropriate coverage 1
• Consider partial nail avulsion if conservative measures fail 1
• Surgical consultation may be necessary for severe cases 2, 3

Supportive Care Measures

• Soak the affected foot in warm water with Epsom salt for 15-20 minutes daily 4, 3
• After soaking, gently place cotton wisps or dental floss under the ingrown nail edge to separate it from the lateral fold 2, 3
• Apply a mid- to high-potency topical steroid to reduce inflammation 2
• Consider gutter splinting to separate the nail edge from the lateral fold for immediate pain relief 2, 3

Prevention of Recurrence

• Provide preventive nail care instructions 1:
  • Wear comfortable, well-fitting shoes and cotton socks
  • Avoid cutting nails too short or rounding the corners
  • Cut nails straight across
  • Apply daily topical emollients to cuticles and periungual tissues
  • Avoid repeated trauma or pressure to the area

Follow-up Recommendations

• Reassess the ingrown toenail after 2 weeks of treatment 1
• If symptoms worsen or do not improve, consider:
  • Obtaining bacterial/fungal cultures if infection is suspected 1
  • Adjusting antibiotic therapy based on culture results 1
  • Referral for partial nail avulsion with or without phenolization for recurrent cases 2, 3

Common Pitfalls to Avoid

• Continuing antibiotics beyond necessary duration (typically 1-2 weeks for mild infections) 1
• Failing to address the mechanical cause of the ingrown nail 2, 3
• Not recognizing when conservative treatment has failed and surgical intervention is needed 1, 3
• Inadequate wound care despite appropriate antibiotic therapy 1