What is the initial management for ingrown toenail in the emergency department?

Initial Management of Ingrown Toenail in the Emergency Department

Start with warm antiseptic soaks using dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily, combined with mid to high-potency topical steroid ointment to the nail folds twice daily, and initiate oral antibiotics with anti-staphylococcal coverage if infection is present. 1, 2

Immediate Assessment

Evaluate the severity by examining for:

• Redness, edema, discharge, and granulation tissue formation 1, 3
• Presence of pus or abscess requiring immediate drainage 1, 2
• Secondary bacterial or fungal superinfection, which occurs in up to 25% of cases 1, 3

First-Line Conservative Management

Antiseptic Soaks and Topical Therapy

• Apply warm antiseptic soaks with dilute vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes twice daily 1, 2
• After soaking, apply 2% povidone-iodine topically twice daily to the affected area 1, 3
• Use mid to high-potency topical steroid ointment to nail folds twice daily to reduce inflammation 1, 2

Immediate Pain Relief Options

• Consider gutter splinting with a plastic tube placed on the lateral edge of the nail for immediate pain relief 1, 2
• Alternatively, place cotton wisps or dental floss under the ingrown lateral nail edge to separate it from underlying tissue 2, 4

Antimicrobial Therapy

When to Start Antibiotics

• If pus is present, obtain cultures and initiate antibiotics immediately 2
• Start with cephalexin as first-line therapy targeting Staphylococcus aureus and gram-positive organisms 1, 2
• If initial treatment fails after 2 weeks, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 1, 3

Important Caveat

Both gram-positive and gram-negative organisms can be implicated, so culture-directed therapy is ideal when possible. 5, 1

Management of Granulation Tissue

If pyogenic granuloma has formed:

• Perform scoop shave removal with hyfrecation 1, 2
• Alternatively, apply silver nitrate for chemical cauterization 1, 3
• For refractory cases, consider topical timolol 0.5% gel twice daily under occlusion 1, 3

Surgical Intervention Threshold

Consider partial nail avulsion if:

• Pain is intolerable despite conservative management 5
• No improvement after 2 weeks of conservative treatment 1, 2
• Painful hematoma or subungual abscess is present 5

Partial nail avulsion combined with phenolization is more effective than surgical excision alone at preventing recurrence, though it carries slightly increased infection risk. 6

Discharge Instructions for Prevention

Provide specific instructions to prevent recurrence:

• Cut nails straight across, not too short 1, 2
• Avoid repeated friction and trauma by wearing comfortable, well-fitting shoes and cotton socks 1, 3
• Apply topical emollients daily to cuticles and periungual tissues 2, 3
• Avoid cutting cuticles or manipulating nail folds 2

Follow-Up Protocol

• Reassess after 2 weeks of treatment 1, 3
• If no improvement or worsening occurs, refer to dermatology or podiatry for consideration of definitive surgical management 1, 3
• Monitor for signs of infection including increased pain, redness, swelling, or purulent drainage 2

Common Pitfalls to Avoid

Do not prescribe antibiotics alone without addressing the mechanical problem - the ingrown nail edge must be separated from the lateral fold either conservatively or surgically. 4 Avoid cutting the nail too short or in a curved fashion, as this worsens the condition and increases recurrence risk. 2, 4