What is the treatment for an infected ingrown toenail?

Treatment of Infected Ingrown Toenail

For an infected ingrown toenail, initiate oral antibiotics targeting Staphylococcus aureus and gram-positive organisms immediately, with cephalexin 500mg four times daily for 7-10 days as first-line treatment, combined with warm soaks and topical antiseptics. 1

Initial Assessment and Grading

Evaluate for signs of infection including:

• Nail fold edema, erythema, and pain 2
• Purulent discharge or nail plate separation 2
• Extent of inflammation and granulation tissue formation 2

Obtain bacterial cultures if purulent discharge is present or infection is clinically suspected before starting antibiotics. 3, 1

Antibiotic Selection

First-Line Options:

• Cephalexin 500mg four times daily for 7-10 days - provides effective coverage against Staphylococcus aureus and Streptococcus species 1
• Amoxicillin-clavulanate 875/125mg twice daily for 7-10 days - offers additional coverage against anaerobes and beta-lactamase producing organisms 1

Alternative Options:

• Clindamycin 300-450mg four times daily - for patients with penicillin allergy 1
• Trimethoprim-sulfamethoxazole or doxycycline - if MRSA is suspected based on local resistance patterns 1

Adjunctive Local Care Measures

Implement the following concurrent treatments:

• Warm soaks with dilute povidone-iodine 2% solution twice daily 2, 1
• Topical antibiotics combined with corticosteroids to reduce inflammation 2, 1
• Elevation of the affected foot to reduce edema 1
• Daily application of mid- to high-potency topical steroid ointment 3

Duration of Treatment

• For mild to moderate infections: 5-7 days may be sufficient if clinical improvement occurs 1
• Extend treatment if no improvement is seen within 5 days 1
• Standard course: 7-10 days for most infected ingrown toenails 1

Follow-Up and Monitoring

Re-evaluate after 2-3 days of antibiotic therapy to ensure improvement. 1

If no improvement after 48-72 hours:

• Consider broader spectrum antibiotics 1
• Reassess for abscess formation requiring drainage 2, 3
• Evaluate need for surgical intervention 2

Surgical Considerations

Partial or total nail avulsion is required if:

• Painful subungual hematoma or abscess develops 2, 3
• Significant granulation tissue is present despite medical management 1
• Grade 3 severity (limiting self-care activities) 2
• No improvement after 2 weeks of conservative management 2

Special Population Considerations

Diabetic Patients:

• Require more aggressive treatment and closer follow-up 1
• Consider broader spectrum antibiotics for moderate to severe infections 1
• Cultures are more strongly recommended 1

Immunocompromised Patients:

• Obtain cultures routinely 1
• Consider earlier surgical intervention 2
• Monitor more closely for treatment failure 1

Common Pitfalls to Avoid

• Do not use prophylactic antibiotics for clean wounds without signs of infection 3
• Do not delay surgical consultation if deep abscess or extensive tissue involvement is present 2, 3
• Do not continue ineffective antibiotic therapy beyond 5-7 days without reassessment 1
• Avoid cutting nails too short during or after treatment, as this predisposes to recurrence 2

Preventive Education Post-Treatment

Once infection resolves, counsel patients on:

• Trimming toenails straight across rather than curved 2
• Wearing comfortable, well-fitting shoes 2
• Avoiding trauma and excessive pressure to the toes 2
• Daily application of topical emollients to periungual tissues 2
• Proper foot hygiene and management of hyperhidrosis 4