What topical steroid is recommended for an ingrown toenail?

Topical Steroid for Ingrown Toenail

For ingrown toenails with edema and inflammation, apply a mid- to high-potency topical steroid ointment to the nail folds twice daily. 1

Specific Steroid Potency Recommendation

• Mid- to high-potency topical corticosteroid ointments are the recommended formulations for ingrown toenails (onychocryptosis) with associated inflammation 1, 2, 3
• The American Academy of Dermatology specifically endorses this potency range for nail fold inflammation and edema 2
• Apply twice daily directly to the inflamed nail folds 1, 2

Clinical Context and Application

When to use topical steroids:

• Presence of nail fold edema or erythema 1
• Pain associated with periungual inflammation 1
• As part of initial conservative management before considering surgical intervention 3

When to AVOID topical steroids:

• Stop immediately if purulent drainage is present - this indicates active infection requiring antibiotics instead 1, 4
• Do not use steroids as monotherapy if bacterial or fungal superinfection is suspected (occurs in up to 25% of cases) 1, 2, 4

Adjunctive Conservative Measures

Topical steroids work best when combined with:

• Topical 2% povidone-iodine twice daily to the affected area 1, 2, 4
• Daily dilute vinegar soaks (50:50 dilution) for 10-15 minutes 1, 2
• Mechanical relief measures such as cotton wisps or dental floss placement under the ingrown nail edge 1, 3
• Taping the lateral nail fold away from the nail plate 1

Treatment Algorithm Based on Severity

Grade 1 (mild edema/erythema):

• Mid- to high-potency topical steroid ointment twice daily 1
• Topical povidone-iodine 2% 1, 2
• Reassess after 2 weeks 1, 2, 4

Grade 2 (edema with pain, discharge, or nail separation):

• Continue topical steroids AND antibiotics/corticosteroid combination 1
• Consider oral antibiotics if infection suspected 1, 2
• Obtain bacterial/viral/fungal cultures 1, 4

Grade 3 or intolerable Grade 2:

• High-potency topical steroids specifically recommended for granulation tissue management 1
• Consider intralesional triamcinolone acetonide for recurrent or severe cases 1
• Surgical intervention may be necessary 1

Critical Pitfalls to Avoid

• Never continue topical steroids if pus develops - this can worsen bacterial infection 1, 4
• Recognize that up to 25% of ingrown toenails have secondary bacterial or fungal superinfection requiring antimicrobial therapy 1, 2, 4
• If no improvement after 2 weeks of conservative treatment including topical steroids, escalate to oral antibiotics or surgical consultation 1, 2, 4