What is the treatment for an ingrown toenail?

Treatment of Ingrown Toenail

Start with conservative management for mild to moderate ingrown toenails, including warm antiseptic soaks twice daily, proper nail trimming technique, and footwear modification; reserve surgical intervention with partial nail avulsion and phenolization for recurrent, severe, or treatment-refractory cases. 1, 2

Initial Conservative Management

Immediate Symptom Relief

• Soak the affected toe in warm, soapy water or dilute antiseptic solution (50:50 vinegar dilution or 2% povidone-iodine) for 10-15 minutes twice daily to reduce inflammation and prevent infection 1, 2
• Apply mid- to high-potency topical corticosteroid ointment to the nail fold twice daily to reduce inflammation 1, 2
• Place wisps of cotton or dental floss under the ingrown lateral nail edge to separate the nail from the inflamed tissue 3
• Apply a gutter splint to the ingrown nail edge for immediate pain relief 3

Footwear and Nail Care Modifications

• Correct inappropriate footwear by wearing comfortable, well-fitting shoes with adequate toe box space to reduce pressure on the toenail 1
• Trim toenails straight across, never rounded at corners, and avoid cutting too short to prevent recurrence 1, 2
• Manage contributing factors such as hyperhidrosis and onychomycosis with appropriate antifungal therapy if cultures are positive 2, 3

When to Suspect Infection

• Look for purulent drainage, significant erythema, or cellulitis that would require antibiotic coverage for Staphylococcus aureus before proceeding with any intervention 2
• Culture any purulent material and treat infection appropriately 4

Surgical Management for Recurrent or Severe Cases

Indications for Surgery

• Recurrent, severe, or treatment-refractory ingrown toenails after conservative measures have been exhausted 5
• Moderate to severe cases where conservative management has failed 3

Surgical Approach

• Partial nail avulsion of the lateral edge of the nail plate combined with phenolization is the most effective approach for preventing symptomatic recurrence, though it carries a slightly increased risk of postoperative infection compared to surgical excision alone 6
• Matrixectomy (chemical, surgical, or electrosurgical) further prevents recurrence 3
• Alternative techniques include the Winograd technique, Vandenbos procedure, radiofrequency ablation, or carbon dioxide laser ablation depending on severity and recurrence patterns 7

Post-Procedure Care

• Continue antiseptic soaks with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily 1
• Apply mid- to high-potency topical steroid ointment to nail folds twice daily 1
• Avoid trauma to the affected digit and wear protective footwear 1
• Note that oral antibiotics before or after phenolization do not improve outcomes 6

Prevention of Recurrence

• Educate patients on proper nail trimming: cut straight across, never rounded, and not too short 1, 2
• Ensure appropriate footwear that accommodates foot shape and fits properly 1, 2
• Apply topical emollients daily to cuticles and periungual tissues to maintain skin barrier function 1
• Treat underlying onychomycosis if present 2

Special Considerations for Diabetic Patients

Critical Pitfall to Avoid

• Diabetic patients at risk of foot ulceration require immediate treatment by an appropriately trained healthcare professional, as ingrown toenails can progress to foot ulceration with significant morbidity 5, 2
• Assess for signs of infection and poor circulation before proceeding with any nail removal 5
• Consider digital flexor tendon tenotomy rather than nail removal as first-line surgical intervention for diabetic patients with non-rigid hammertoes 5
• Provide integrated foot care every 1-3 months for diabetic patients at moderate-to-high risk (IWGDF risk 2-3) 2

Key Clinical Pearls

Conservative treatments work well for mild to moderate cases but have higher recurrence rates than surgical approaches 3. The choice between conservative and surgical management depends on severity, recurrence pattern, and patient factors, particularly diabetes status. Surgical approaches are superior to nonsurgical ones for preventing recurrence 3, with partial nail avulsion plus phenolization being the gold standard for definitive treatment 6.