What is the treatment for an ingrown toenail?

Treatment of Ingrown Toenail

Start with conservative management using antiseptic soaks and topical corticosteroids, reserving surgical intervention for recurrent or severe cases, with partial nail avulsion plus phenolization being the most effective surgical approach.

Initial Conservative Management

For mild to moderate ingrown toenails, begin with a structured conservative approach that addresses both infection risk and inflammation:

• Apply dilute vinegar soaks (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily to the affected nail fold 1, 2
• Apply mid- to high-potency topical corticosteroid ointment to the nail fold twice daily to reduce inflammation and edema 3, 1
• Tape the nail fold away from the nail plate or use cotton packing/dental floss insertion under the ingrown nail edge to separate the lateral nail from underlying tissue 3, 4
• Consider gutter splinting with a flexible tube placed on the lateral edge of the nail, which provides immediate pain relief 3, 4

When to Add Antibiotics

Antibiotics are indicated only when infection is present, not prophylactically:

• If you observe purulent drainage, significant erythema, or localized cellulitis, culture the drainage and initiate oral antibiotics with coverage for Staphylococcus aureus and gram-positive organisms 1, 2
• For pediatric patients requiring antibiotics, use amoxicillin-clavulanate dosed appropriately by weight as first-line therapy 1
• Note that oral antibiotics before or after phenolization do not improve outcomes in the absence of active infection 5

Surgical Intervention for Recurrent or Severe Cases

When conservative measures fail or the ingrown toenail is recurrent/severe, surgical intervention becomes necessary:

• Partial nail avulsion combined with phenolization is the most effective surgical approach, superior to surgical excision alone in preventing symptomatic recurrence 5, 4
• Alternative surgical options include scoop shave removal with hyfrecation or silver nitrate application for granulation tissue 3
• For recurrent, severe, or treatment-refractory cases with onychocryptosis, consider intralesional triamcinolone acetonide in combination with other modalities 3
• Be aware that phenolization carries a slightly increased risk of postoperative infection compared to surgical excision without phenolization, though it is more effective at preventing recurrence 5

Prevention and Long-Term Management

Preventing recurrence requires addressing underlying anatomic and behavioral factors:

• Trim toenails straight across, never rounded at the corners, and avoid cutting them too short 1, 2
• Ensure comfortable, well-fitting shoes with adequate toe room and cotton socks to prevent pressure and friction 1
• Treat underlying onychomycosis with appropriate antifungal therapy if fungal infection is present, as this can contribute to nail deformity and recurrence 3, 2
• Implement daily foot washing with careful drying between toes and application of emollients to maintain skin barrier function 2

Special Considerations for High-Risk Patients

Diabetic patients and those at risk for foot ulceration require immediate professional intervention:

• For diabetic patients (IWGDF risk 2-3), provide immediate treatment by a trained healthcare professional, as ingrown toenails can progress to foot ulceration with significant morbidity and mortality 3, 2
• Implement integrated foot care every 1-3 months for diabetic patients at moderate-to-high risk, including prompt treatment of any pre-ulcerative lesions 3, 2
• Consider extra-depth shoes or custom-made footwear if foot deformities are present in diabetic patients 2

Common Pitfalls to Avoid

• Do not use topical steroids if purulent infection is present—stop steroids and treat the infection first 3
• Avoid prophylactic antibiotics in the absence of clinical infection, as they do not improve outcomes 5
• Do not attempt surgical procedures without proper training, as improper technique can worsen the condition and increase infection risk 3
• Do not overlook family members as sources of onychomycosis or tinea pedis that can contribute to secondary infection 1