What's the next step for treating erythema (redness) on my right toe that's not improving with mupirocin (mupirocin) for an ingrown toenail?

Treatment Escalation for Ingrown Toenail with Persistent Erythema

Switch from mupirocin to oral antibiotics, specifically amoxicillin-clavulanate (Augmentin) 500/125 mg every 12 hours, combined with topical povidone-iodine ointment, and reassess in 2 weeks. 1, 2

Why Mupirocin Failed

Mupirocin is indicated for superficial skin infections and should show clinical response within 3-5 days. 3 Since your toe erythema has not improved, this represents treatment failure requiring escalation. 3 While mupirocin has good activity against staphylococci and streptococci, 4, 5 it may be insufficient for paronychia associated with ingrown toenails, which often involves deeper tissue inflammation and potential polymicrobial infection. 1

Next Steps: Grade 2 Paronychia Management

Your presentation suggests Grade 2 paronychia (nail fold erythema with pain, not improving with topical therapy). 1 The evidence-based approach is:

Immediate Actions:

• Start oral antibiotics: Amoxicillin-clavulanate 500/125 mg twice daily 2 OR doxycycline 100 mg twice daily for broader coverage 1
• Add topical povidone-iodine 2% ointment applied to the affected area 1
• Consider bacterial/fungal cultures if infection is suspected, as up to 25% of paronychia cases have secondary fungal involvement 1, 2

Duration and Monitoring:

• Continue treatment and reassess after 2 weeks 1
• If worsening or no improvement after 2 weeks, escalate to Grade 3 management 1

When to Escalate Further (Grade 3)

If the erythema worsens or fails to improve after 2 weeks of oral antibiotics, you need: 1

• Obtain bacterial/viral/fungal cultures to guide antibiotic selection 1
• Consider partial nail avulsion or other surgical intervention 1
• Switch antibiotics based on culture results (e.g., oral quinolones if resistant organisms) 1

Critical Pitfalls to Avoid

• Don't continue mupirocin monotherapy beyond 3-5 days without response 3
• Don't assume it's purely bacterial - fungal superinfection occurs in 25% of cases and requires antifungal therapy if antibiotics fail 1, 2
• Don't delay cultures in severe cases - both gram-positive and gram-negative organisms can be involved 1
• Avoid tight shoes and trauma to the affected toe during treatment 1

Alternative Antibiotic Options

If amoxicillin-clavulanate is contraindicated or not tolerated: 1

• Doxycycline 100 mg twice daily (preferred for anti-inflammatory effects) 1
• Minocycline 50 mg twice daily 1
• Oral quinolones if gram-negative coverage needed 1