What are the steps to remove an ingrown toenail?

Ingrown Toenail Removal: Steps and Equipment

For mild to moderate ingrown toenails, begin with conservative management using antiseptic soaks, topical steroids, and gutter splinting; reserve surgical partial nail avulsion with phenol matrixectomy for moderate-to-severe cases or when conservative treatment fails, as this combination provides the best recurrence prevention. 1, 2, 3

Initial Assessment

• Evaluate severity by examining for redness, edema, purulent discharge, granulation tissue formation, and presence of abscess 1
• Check for infection signs including cellulitis, pus, or significant erythema that would require antibiotic coverage for Staphylococcus aureus before any procedure 4, 2
• Assess contributing factors such as improper nail trimming, tight footwear, hyperhidrosis, onychomycosis, or trauma 2, 3

Conservative Management (Mild to Moderate Cases)

Equipment Needed:

• Dilute vinegar solution (50:50 with water) or 2% povidone-iodine 1, 4
• Mid to high-potency topical corticosteroid ointment 1, 4
• Cotton wisps or dental floss 2, 3
• Plastic tube for gutter splinting 1
• Basin for soaking 2, 5

Step-by-Step Conservative Approach:

1. Antiseptic soaking: Have patient soak affected toe in warm dilute vinegar (50:50 dilution) or 2% povidone-iodine solution for 10-15 minutes twice daily 1, 4

2. Topical anti-inflammatory: Apply mid to high-potency topical corticosteroid ointment to the nail fold twice daily to reduce inflammation 1, 4, 2

3. Nail edge separation: Place cotton wisps or dental floss under the ingrown lateral nail edge after soaking to lift the nail away from the inflamed tissue 2, 3

4. Gutter splinting: Insert a plastic tube with a lengthwise incision on the lateral edge of the nail to encapsulate and separate it from the nail fold—this provides immediate pain relief 6, 1, 2

5. Antimicrobial coverage if infected: If purulent drainage or cellulitis is present, start oral cephalexin as first-line therapy; switch to sulfamethoxazole-trimethoprim if initial treatment fails or MRSA is suspected 1

Surgical Management (Moderate to Severe or Recurrent Cases)

Equipment Needed:

• Local anesthetic (lidocaine without epinephrine for digital block) 2
• Sterile scissors or nail splitter 2
• Hemostat or nail elevator 2
• 88% phenol solution 3
• Cotton-tipped applicators 3
• Isopropyl alcohol for phenol neutralization 3
• Sterile gauze and dressing materials 2

Step-by-Step Surgical Approach:

Partial Nail Avulsion with Phenol Matrixectomy (most effective for preventing recurrence):

1. Anesthesia: Perform digital block using lidocaine without epinephrine at the base of the toe 2, 3

2. Nail plate removal: Using sterile scissors or nail splitter, cut the lateral 3-4mm of the nail plate longitudinally from the distal edge to the proximal nail fold 2, 3

3. Avulsion: Grasp the cut nail segment with a hemostat and remove it by rotating and pulling in one smooth motion 2, 3

4. Phenol application: Apply 88% phenol solution to the exposed nail matrix using a cotton-tipped applicator for 2-3 minutes to destroy the matrix and prevent regrowth 3

5. Neutralization: Flush the area with isopropyl alcohol to neutralize the phenol 3

6. Dressing: Apply sterile gauze and instruct patient on daily dressing changes 2, 3

Important caveat: Partial nail avulsion combined with phenolization is more effective than surgical excision alone at preventing recurrence, though it carries a slightly increased risk of postoperative infection 3

Management of Complications

• For pyogenic granuloma formation: Perform scoop shave removal with hyfrecation or apply silver nitrate 6, 1
• For recurrent/severe cases: Consider intralesional triamcinolone acetonide injection 6, 1
• For treatment-refractory cases: Topical timolol 0.5% gel twice daily under occlusion may provide benefit 6, 1

Post-Procedure Care and Prevention

• Trim toenails straight across, never rounded at corners, and avoid cutting too short 1, 4, 7
• Wear comfortable, well-fitting shoes with adequate toe room and cotton socks to prevent pressure 7, 2
• Treat underlying conditions such as onychomycosis with appropriate antifungal therapy if cultures are positive 4
• Apply emollients regularly to cuticles and periungual tissues to maintain skin barrier function 4
• Reassess after 2 weeks of conservative treatment; if no improvement, consider surgical intervention 1

Critical pitfall to avoid: Do not perform surgical procedures in the presence of active infection without first treating with appropriate antibiotics, as this significantly increases complication risk 4, 2