Treatment of Ingrown Toenail Infection
For an infected ingrown toenail, treatment should be stratified by severity: mild infections (Grade 1) require topical antiseptics like povidone-iodine 2%, moderate infections (Grade 2) need cultures and consideration of oral antibiotics if spreading cellulitis is present, and severe infections (Grade 3) require oral antibiotics plus partial nail avulsion to remove the infectious source. 1
Initial Assessment and Grading
Classify the ingrown toenail by severity to guide treatment 1:
- Grade 1 (Mild): Nail fold edema or erythema with cuticle disruption 1
- Grade 2 (Moderate): Nail fold edema or erythema with pain, discharge, or nail plate separation 1
- Grade 3 (Severe): Severe inflammation requiring surgical intervention 1
Treatment Algorithm by Severity
Grade 1 (Mild Infection)
- Apply topical povidone-iodine 2% or topical antibiotics with corticosteroids 1
- Reassess after 2 weeks; if worsening, escalate to Grade 2 treatment 1
- Consider conservative measures: soak in warm water, place cotton wisps or dental floss under the ingrown nail edge, or apply gutter splinting 2, 3
Grade 2 (Moderate Infection)
- Obtain bacterial, viral, and fungal cultures before initiating treatment 1
- Apply topical povidone-iodine 2% or topical antibiotics with corticosteroids 1
- Consider oral antibiotics if signs of spreading infection (cellulitis) are present 1
- Reassess after 2 weeks 1
- Gutter splinting provides immediate pain relief and separates the nail from the lateral fold 2
Grade 3 (Severe Infection)
- Interrupt normal activities until improvement occurs 1
- Obtain bacterial, viral, and fungal cultures 1
- Implement both topical treatments AND oral antibiotics 1
- Consider partial nail avulsion to remove the source of infection 1, 2
- Reassess after 2 weeks 1
Surgical Intervention
Partial nail avulsion combined with phenolization is more effective than surgical excision alone at preventing recurrence, though it carries a slightly increased risk of postoperative infection 3. Surgical approaches are superior to nonsurgical ones for preventing recurrence 2.
Common surgical techniques include 4, 2:
- Partial avulsion of the lateral nail edge (most common) 2
- Chemical matricectomy with phenol 3, 5
- Winograd technique, Vandenbos procedure, or other specialized approaches 4
Important caveat: While rare, surgical site infections can lead to devastating complications including gangrene and amputation, particularly in high-risk patients 6. This underscores the importance of appropriate patient selection for ambulatory procedures and vigilant postoperative monitoring.
Adjunctive Treatments
- Urea 40% can be applied to damaged or ingrown nails twice daily to promote debridement and healing 7
- Manage underlying onychomycosis if present, as this predisposes to recurrence 8, 2
- Treat hyperhidrosis to reduce moisture 1, 2
Prevention of Recurrence
- Educate on proper nail trimming: cut toenails straight across 8, 1
- Apply topical emollients daily to cuticles and periungual tissues 1
- Recommend properly fitting shoes with adequate toe box space 1, 2
- Use absorbent socks and antifungal powders in shoes 1
- Address footwear habits and nail care practices that contribute to recurrence 2
Special Populations
In diabetic patients at risk for foot ulceration, provide appropriate treatment for ingrown toenails to help prevent foot ulcers 8. These patients require integrated foot care including professional foot treatment, as complications like cellulitis can further compromise limbs already affected by diabetes or peripheral vascular disease 8.