What is the treatment for a toddler with an ingrown toenail?

Treatment of Ingrown Toenail in Toddlers

For a toddler with an ingrown toenail, begin with conservative management including warm water soaks, proper nail trimming straight across, and cotton wisps or dental floss placement under the ingrown edge, reserving surgical intervention only for severe or recurrent cases that fail conservative measures. 1, 2

Initial Conservative Management

First-Line Approach

• Soak the affected toe in warm, soapy water or Epsom salt solution for 10-15 minutes twice daily to soften the nail and reduce inflammation 3, 1, 2
• Apply topical povidone iodine 2% twice daily to the affected area as the primary antiseptic agent 4, 5
• Place small wisps of cotton or dental floss under the ingrown lateral nail edge after soaking to lift the nail away from the inflamed tissue 1, 2
• Apply a mid- to high-potency topical corticosteroid ointment to the nail fold twice daily to reduce inflammation 4, 1

Preventive Nail Care Education

• Trim toenails straight across, never rounded at the corners, and avoid cutting them too short 6, 5
• Ensure the child wears comfortable, well-fitting shoes with adequate toe room and cotton socks to prevent pressure and friction 6, 5
• Avoid repeated trauma or pressure to the affected toe 6, 5
• Apply daily topical emollients to cuticles and periungual tissues 6, 5

When to Add Antibiotics

Signs Requiring Antibiotic Therapy

• If localized cellulitis, purulent drainage, or significant erythema develops despite conservative measures, consider oral antibiotics with coverage for Staphylococcus aureus and gram-positive organisms 4, 5
• For toddlers requiring antibiotics, amoxicillin-clavulanate (Augmentin) dosed appropriately by weight is the recommended first-line agent 7, 5
• Obtain bacterial cultures before starting antibiotics in severe cases or treatment failures 4, 7
• Continue antibiotics for 1-2 weeks for mild infections, avoiding prolonged courses 5

Important Caveat

• Avoid applying topical corticosteroids if purulent drainage is present until the infection is adequately treated with antibiotics 4
• Secondary bacterial or fungal infections occur in up to 25% of paronychia cases, so reassess if not improving 6, 4, 7

Surgical Intervention Criteria

When Conservative Treatment Fails

• Reassess after 2 weeks of conservative management; if symptoms worsen or do not improve, consider surgical options 4, 5
• Surgical approaches are reserved for moderate to severe cases with recurrent symptoms despite adequate conservative treatment 1, 2
• Partial nail avulsion with phenolization is the most effective surgical approach for preventing recurrence in children, though it carries a slightly increased risk of postoperative infection compared to avulsion alone 2

Surgical Options for Severe Cases

• Partial avulsion of the lateral edge of the nail plate is the most common surgical approach 1, 2
• Chemical matricectomy with phenol prevents recurrence more effectively than simple nail removal 3, 2
• For toddlers with excessive periungual tissue and curved nails who fail multiple treatments, more definitive procedures may be considered, though these are rarely needed in this age group 8, 9

Follow-Up and Monitoring

• Monitor closely for early signs of pyogenic granuloma development, which may require additional intervention 6
• If the child has recurrent ingrown toenails despite proper nail care, consider referral to a podiatrist for specialized assessment and preventive correction of nail curvature 6, 5
• Examine parents and siblings for onychomycosis and tinea pedis, as these can be sources of secondary infection in children 6

Common Pitfalls to Avoid

• Never cut the nail too short or round the corners, as this is the most common behavioral factor contributing to ingrown toenails 1, 2
• Do not continue antibiotics beyond the necessary duration without reassessing for treatment response 5
• Avoid inadequate wound care despite appropriate antibiotic therapy, as topical measures remain essential 5
• In toddlers, the nail plate is thinner and grows faster than in adults, making conservative topical treatment often more successful than in adults 6