What is the treatment for an ingrown toenail?

Treatment of Ingrown Toenail

For ingrown toenails, begin with conservative management including daily antiseptic soaks (dilute vinegar 50:50 or 2% povidone-iodine) for 10-15 minutes twice daily plus mid-to-high potency topical steroid ointment to nail folds twice daily, reserving surgical intervention (partial nail avulsion with phenolization) for cases that fail to improve after 2-4 weeks or present with severe infection. 1, 2

Initial Conservative Management (Mild to Moderate Cases)

Daily antiseptic soaks:

• Soak affected toe in dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily 1, 2
• After soaking, apply mid-to-high potency topical steroid ointment to nail folds twice daily to reduce inflammation 1, 2

Mechanical relief techniques:

• Place cotton wisps or dental floss under the ingrown lateral nail edge to separate it from underlying tissue 1, 3
• Consider gutter splinting using a plastic tube with lengthwise incision placed on lateral nail edge 1
• Trim nails straight across (not rounded at corners, not too short) 2, 3

Footwear modification:

• Wear comfortable, well-fitting shoes with adequate toe box space to reduce pressure 2
• Use cotton socks and avoid repeated trauma 1

Management of Infection

If pus is present:

• Obtain bacterial cultures before initiating antibiotics 1
• Start antibiotics with coverage against Staphylococcus aureus and gram-positive organisms 1
• Continue antiseptic soaks throughout treatment 1, 2

For granulation tissue:

• Perform scoop shave removal with hyfrecation or apply silver nitrate 1
• For recurrent or severe granulation tissue, consider doxycycline 100 mg twice daily with 1-month follow-up 1

When to Escalate to Surgical Management

Indications for surgery:

• Persistent pain or drainage beyond 2-4 weeks of conservative treatment 1
• Severe cases with significant infection or extensive granulation tissue 3
• Recurrent ingrown nails despite proper conservative management 4, 3

Surgical approach:

• Partial nail avulsion combined with phenolization is the most effective surgical treatment, superior to nail excision alone in preventing recurrence 4
• This combination has slightly increased risk of postoperative infection compared to excision alone, but significantly better recurrence prevention 4
• Alternative ablation methods include electrocautery, radiofrequency, or carbon dioxide laser of the nail matrix 4, 5

Special Populations

Diabetic patients:

• Ingrown toenails must be treated by appropriately trained healthcare professionals to prevent foot ulceration 6, 2
• This is particularly critical in patients at moderate-to-high risk of foot ulceration (IWGDF risk 2-3) 6
• For diabetic patients with non-rigid hammertoes and nail changes, consider digital flexor tendon tenotomy or orthotic interventions 6, 2

Suspected fungal infection:

• Obtain fungal cultures if onychomycosis is contributing to ingrown nail 2
• Initiate appropriate antifungal therapy based on culture results 6, 2

Post-Treatment Care and Prevention

Immediate post-procedure management:

• Continue antiseptic soaks with dilute vinegar or 2% povidone-iodine twice daily 1, 2
• Apply mid-to-high potency topical steroid ointment to nail folds twice daily if inflammation persists 1, 2
• Reassess wound healing at 2 weeks to determine if additional interventions needed 1
• Monitor for signs of infection: increased pain, redness, swelling, or purulent drainage 1

Long-term prevention:

• Educate on proper nail trimming: cut straight across, not too short, avoid rounding corners 1, 2, 3
• Apply topical emollients daily to cuticles and periungual tissues 1, 2
• Avoid cutting cuticles or manipulating nail folds 1
• Wear protective gloves when working with water or chemicals 1, 2
• Maintain good hand hygiene and avoid artificial nails 1

Common Pitfalls to Avoid

• Do not delay surgical referral beyond 2-4 weeks if conservative management fails, as this increases risk of complications 1
• In diabetic patients, never attempt self-treatment or delay professional evaluation, as this significantly increases ulceration risk 6
• Avoid prescribing oral antibiotics before or after phenolization routinely, as they do not improve outcomes 4
• Do not round nail corners during trimming, as this is a primary cause of recurrence 2, 3