What is the best treatment for a reoccurring ingrown toenail on the great toe?

Treatment of Recurrent Ingrown Toenail on the Great Toe

For a recurrent ingrown toenail on the great toe, perform partial nail avulsion with phenolization (chemical matricectomy) as the definitive treatment, as this provides superior recurrence prevention compared to conservative measures or surgery without matricectomy. 1, 2

Initial Assessment and Conservative Trial

Before proceeding to definitive surgical management, assess whether this is truly a recurrence or inadequately treated initial presentation:

• Examine for contributing factors: Check for onychomycosis (fungal infection), hyperhidrosis, improper footwear, and poor nail trimming technique, as these perpetuate recurrence 2
• Rule out infection: Look for purulent drainage, significant erythema, or cellulitis that would require antibiotic coverage for Staphylococcus aureus before any procedure 3
• In diabetic patients specifically: Provide immediate appropriate treatment by a trained healthcare professional, as ingrown toenails can progress to foot ulceration with significant morbidity 4, 5

Conservative Management (Only for Mild Cases or Pre-Operative Preparation)

If infection is present or you need to temporize before definitive surgery:

• Antiseptic soaks: Warm water with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily 5, 6
• Topical anti-inflammatory: Apply mid- to high-potency topical corticosteroid ointment to the nail fold twice daily to reduce inflammation 3, 5, 2
• Antibiotics if needed: For localized cellulitis, use amoxicillin-clavulanate or cephalexin targeting gram-positive organisms 3, 6

Critical caveat: Conservative measures alone have high recurrence rates and should NOT be the endpoint for recurrent ingrown toenails 1, 2

Definitive Surgical Treatment (Recommended for Recurrence)

Partial nail avulsion with phenolization is the gold standard for recurrent ingrown toenails:

• Technique: Remove the lateral edge of the nail plate and apply 88% phenol to the exposed nail matrix for chemical matricectomy 1, 2
• Evidence superiority: This combination is more effective at preventing symptomatic recurrence compared to surgical excision without phenolization, though it carries a slightly increased risk of postoperative infection 1
• Alternative matrix destruction methods: Electrocautery, radiofrequency ablation, or carbon dioxide laser ablation of the nail matrix are equally effective alternatives to phenolization 1, 7

Alternative Surgical Approach (For Cosmetic Concerns)

• Vandenbos procedure: Removes a large volume of soft tissue surrounding the nail plate without matricectomy, providing excellent cosmetic results with complete nail preservation 8
• Indication: Consider this when cosmetic outcome is a priority and the patient accepts that long-term recurrence data are more limited 8

Post-Procedure Care

• Continue antiseptic soaks with dilute vinegar or 2% povidone-iodine twice daily for 10-15 days 5, 6
• Apply topical corticosteroid to reduce inflammation during healing 5, 6
• Avoid trauma to the affected digit and wear protective footwear during healing 5, 6

Prevention of Future Recurrence

Patient education is essential to prevent another recurrence:

• Proper nail trimming: Cut toenails straight across, never rounded at corners, and avoid cutting too short 4, 3, 5, 2
• Appropriate footwear: Wear comfortable, well-fitting shoes with adequate toe box space and cotton socks 3, 5, 2
• Treat underlying conditions: Address onychomycosis with appropriate antifungal therapy if cultures are positive 4, 5, 2
• Hygiene measures: Daily foot washing with careful drying between toes, and application of emollients to maintain skin barrier function 4, 5, 6

Special Consideration for Diabetic Patients

• Integrated foot care: Diabetic patients at moderate-to-high risk (IWGDF risk 2-3) require professional foot care every 1-3 months, including prompt treatment of ingrown toenails to prevent progression to foot ulceration 4
• Footwear prescription: Consider extra-depth shoes or custom-made footwear if foot deformities are present 4

Bottom line: Do not continue temporizing with conservative measures for recurrent ingrown toenails—proceed to partial nail avulsion with phenolization for definitive cure and recurrence prevention.