What is the treatment for an infected ingrown toenail?

Treatment of Infected Ingrown Toenail

For an infected ingrown toenail, initiate treatment with topical povidone-iodine 2% twice daily combined with warm water soaks, mid-to-high potency topical corticosteroid ointment to the nail folds twice daily, and oral antibiotics (cephalexin or amoxicillin-clavulanate) for 1-2 weeks; if no improvement after 2 weeks or if severe infection is present, proceed to partial nail avulsion with phenolization. 1, 2, 3

Initial Medical Management

Topical Antiseptic Therapy

• Apply topical povidone-iodine 2% twice daily as the most evidence-based first-line antiseptic agent 1, 2
• Perform daily dilute vinegar soaks (50:50 dilution) to nail folds for 10-15 minutes twice daily as an adjunctive measure 1, 3
• These antiseptic soaks help sterilize the subcuticular space where infection develops 1

Anti-inflammatory Treatment

• Apply mid-to-high potency topical corticosteroid ointment to the nail folds twice daily to reduce inflammation and edema 1, 2, 3
• Avoid topical steroids if purulent drainage is present until infection is adequately treated 1, 2

Oral Antibiotic Selection

• For mild-to-moderate infections, prescribe cephalexin or amoxicillin-clavulanate for 1-2 weeks 2, 3
• Avoid clindamycin due to inadequate coverage for some streptococcal species and increasing resistance patterns 2
• Obtain bacterial cultures before starting antibiotics if purulent drainage is present 1, 2
• Up to 25% of cases have bacterial or fungal superinfections involving both gram-positive and gram-negative organisms 1, 2

Mechanical Relief Measures

Conservative Techniques

• Tape the nail fold away from the nail plate to reduce pressure 3
• Place cotton wisps or dental floss under the ingrown nail edge to separate it from underlying tissue 3, 4
• Apply a gutter splint to the ingrown nail edge for immediate pain relief 3, 4

Surgical Intervention Criteria

When to Escalate to Surgery

• Reassess after 2 weeks of medical management; if no improvement, escalate to surgical intervention 1, 2
• Severe infections with deep abscess, extensive tissue involvement, or substantial necrosis require immediate surgical consultation 3
• Recurrent or treatment-refractory cases warrant surgical management 3, 5

Surgical Approach

• Partial nail avulsion combined with phenolization is the most effective surgical treatment for preventing symptomatic recurrence 5, 4
• This approach is superior to complete nail excision without phenolization, though it carries a slightly increased risk of postoperative infection 5
• Alternative matrix destruction methods include electrocautery, radiofrequency, or carbon dioxide laser ablation 5, 6

Duration of Antibiotic Therapy

• Continue antibiotics for 1-2 weeks for mild infections, with some requiring an additional 1-2 weeks 3
• For moderate-to-severe infections, 2-4 weeks is usually sufficient, depending on the adequacy of debridement and wound vascularity 3

Critical Pitfalls to Avoid

• Do not delay surgical intervention beyond 2 weeks if medical management fails 1, 2
• Do not use topical steroids in the presence of purulent drainage 1, 2
• Do not prescribe clindamycin as first-line therapy 2
• Do not use oral antibiotics alone without addressing the mechanical component through either conservative measures or surgery 5, 4