Management of Ingrown Toenail with Concurrent Onychomycosis
Fungal infection does not need to be treated before wedge resection, but mechanical removal of thickened, infected nail tissue may be necessary at the time of surgery to optimize outcomes. The presence of onychomycosis should not delay definitive surgical management of the ingrown toenail, though concurrent treatment of both conditions is recommended.
Rationale for Proceeding with Surgery
Surgical Management Takes Priority
Ingrown toenails with thickening and curvature require definitive surgical intervention regardless of fungal infection status 1. The International Working Group on the Diabetic Foot guidelines specifically recommend treating ingrown toenails promptly to prevent ulceration and complications 1.
Wedge resection addresses the mechanical problem causing symptoms (pain, inflammation, infection from the ingrown nail), which is distinct from the fungal infection 2, 3. Delaying surgery to treat fungus first would prolong patient suffering without clear benefit.
Fungal Treatment Considerations Around Surgery
Mechanical debridement during surgery can remove fungal-laden tissue 1. The British Association of Dermatologists notes that "mechanical intervention may be necessary to remove the dermatophytomas within the nail plate or nail bed" 1. This can be accomplished during the wedge resection procedure itself.
Thickened nails with fungal infection (>2mm thickness) are resistant to antifungal therapy alone 1. The guidelines explicitly state that nail characteristics including thickness and dermatophytoma contribute to antifungal treatment failure 1. Therefore, attempting to treat the fungus first in a severely thickened, curved nail would likely fail anyway.
Surgical avulsion followed by topical antifungal therapy has shown disappointing results 1. A randomized controlled trial demonstrated this approach is not recommended based on available evidence 1. This suggests that surgery-first approaches without pre-treatment of fungus are already established practice.
Optimal Management Algorithm
Immediate Steps
Confirm fungal infection with mycological testing (microscopy and culture) if not already done 1. Treatment should not commence without confirmation 1.
Proceed with wedge resection without delay 1, 2, 3. The surgical procedure should include:
Concurrent Antifungal Management
Initiate systemic antifungal therapy perioperatively or immediately post-operatively 1. For dermatophyte onychomycosis (most common):
Topical antifungals alone are insufficient for thickened nails with matrix involvement 1, 5. Topical therapy is only appropriate for superficial white onychomycosis or very distal infection affecting <80% of nail plate 1.
Critical Pitfalls to Avoid
Common Errors
Do not delay surgery to complete a 12-week antifungal course first 1, 2. This prolongs morbidity from the ingrown nail without evidence of benefit.
Do not rely on topical antifungals for thick, curved nails 1, 5. The nail plate acts as a barrier, and drug concentration drops 1000-fold from outer to inner surface 1.
Do not assume surgical removal alone will cure the fungus 1. Systemic antifungal therapy must be added to prevent recurrence, as fungal elements persist in surrounding tissue and footwear 1.
Post-Operative Considerations
Continue antifungal therapy for the full 12-week course even after surgical healing 1. Toenails require up to 18 months to fully grow out fungus-free 1.
Address reinfection risk factors 1:
Special Populations
In diabetic patients, treat both conditions urgently 1. Fungal infections disrupt skin integrity and provide bacterial entry points leading to ulcers, cellulitis, and osteomyelitis 1. The strong recommendation is to treat fungal infections and ingrown nails promptly in at-risk diabetic patients 1.
In immunocompromised patients, prefer terbinafine or fluconazole over itraconazole due to drug interaction risks with antiretrovirals 1.