Treatment of Onychocryptosis (Ingrown Toenail)
For mild to moderate onychocryptosis, begin with conservative measures including taping the nail fold away from the nail plate, dental floss or cotton packing under the ingrown edge, and antiseptic soaks; for severe, recurrent, or refractory cases, partial nail avulsion with phenolization of the lateral nail matrix is the most effective surgical approach. 1, 2
Conservative Treatment Approaches
Initial Management for Early-Stage Disease
- Taping technique: Tape the nail fold away from the nail plate to separate the ingrown edge from underlying tissue 1
- Dental floss nail splinting: Insert dental floss under the ingrown nail to separate the lateral nail edge from the underlying tissue 1
- Cotton packing: Place cotton wisps under the ingrown nail edge to lift it away from the nail fold 2
- Flexible tube splinting: Place a plastic tube with a lengthwise incision on the lateral edge of the nail to encapsulate it 1
- Antiseptic soaks: Daily dilute vinegar soaks (50:50 dilution) to nail folds twice daily for 10-15 minutes 1
- Topical povidone-iodine 2%: Apply twice daily to reduce inflammation and prevent infection 1
When Edema, Pain, or Granulation Tissue Present
- Mid to high-potency topical corticosteroid ointment: Apply to nail folds twice daily to reduce inflammation 1
- Topical timolol 0.5% gel: Apply twice daily under occlusion for granulation tissue (pyogenic granuloma) 1
- Silver nitrate cauterization: Chemical cauterization for granulation tissue 1
- High-potency topical steroids: For persistent granulation tissue 1
When Infection is Present
- Culture purulent drainage and treat accordingly 1
- Oral antibiotics: For documented infection, though antibiotics before or after surgical procedures do not improve outcomes 2
- Stop topical steroids if infection is present 1
- Combination topical therapy: Antibiotics with corticosteroids for infected cases 1
Surgical Treatment Approaches
Indications for Surgery
Surgery is indicated for severe (grade 3), recurrent, or treatment-refractory onychocryptosis 1, 3, 4
Preferred Surgical Method
- Partial nail avulsion with phenolization: This is the most effective, safe, and commonly performed surgical technique 3, 2
- Phenol cauterization of the lateral nail matrix prevents recurrence more effectively than surgical excision alone 2
- Partial nail avulsion combined with phenolization is more effective at preventing symptomatic recurrence compared to surgical excision without phenolization, though it carries a slightly increased risk of postoperative infection 2
Alternative Surgical Options
- Scoop shave removal with hyfrecation: For granulation tissue removal 1
- Acrylic treatment with gutter splint: For structural correction 1
- Complete nail excision: Rarely indicated; more destructive procedures are seldom performed nowadays 3
- Intralesional triamcinolone acetonide: For recurrent or severe cases with persistent granulation tissue 1
Treatment Algorithm by Severity
Stage I (Early Disease)
Conservative measures are most effective: taping, dental floss splinting, antiseptic soaks, and topical povidone-iodine 3, 4, 2
Stage II-III (Moderate to Severe)
Combination of conservative measures with topical corticosteroids and consideration of surgical intervention if no improvement after 2 weeks 1, 4
Stage IV or Recurrent Disease
Surgical procedures required, with partial nail avulsion and phenolization as the gold standard 3, 4, 2
Important Caveats
- Reassess after 2 weeks: If reactions worsen or do not improve with conservative treatment, surgical intervention is necessary 1
- Avoid cutting nails too short: This is a common predisposing factor; nails should be trimmed straight and not too short 1
- Proper footwear: Wearing comfortable, well-fitting shoes and cotton socks prevents recurrence 1
- Podiatry referral: Consider for preventive correction of nail curvature in recurrent cases 1
- Oral antibiotics do not improve surgical outcomes: They should not be routinely used before or after phenolization 2