What is the treatment for a patient with nail pain and no nail growth, suspected to be an ingrown nail or nail infection?

Treatment of Ingrown Toenail with Nail Pain

For a patient presenting with nail pain suspected to be an ingrown toenail, begin with conservative management including warm soaks, topical corticosteroids, and cotton/dental floss placement under the nail edge; if this fails or if there are signs of infection (redness, swelling, purulent drainage), initiate oral antibiotics targeting Staphylococcus aureus, and proceed to partial nail avulsion with phenolization for definitive treatment. 1, 2, 3

Initial Assessment and Conservative Management

First-Line Conservative Measures

• Immediately assess for signs of infection: increased pain, redness, swelling, purulent drainage, or warmth around the nail fold 1
• Obtain bacterial cultures if pus is present or infection is clinically suspected before starting antibiotics 1
• Begin conservative treatment for mild to moderate cases without infection:
  • Daily warm water or Epsom salt soaks 4, 2
  • Apply mid- to high-potency topical steroid ointment to reduce inflammation and edema 1, 2
  • Place wisps of cotton or dental floss under the ingrown lateral nail edge to lift the nail away from the nail fold 2, 3
  • Trim away the ingrown portion of the nail if accessible 4
  • Correct inappropriate footwear and address hyperhidrosis 2

Gutter Splinting Technique

• Application of a gutter splint to the ingrown nail edge provides immediate pain relief by separating the nail plate from the lateral fold 2
• Alternative techniques include cotton nail cast with cyanoacrylate adhesive or taping the lateral nail fold 2

Antibiotic Therapy When Infection is Present

Indications for Antibiotics

• Initiate oral antibiotics immediately if infection is suspected based on clinical signs (localized cellulitis, inflammation, purulent drainage) 1, 4
• Do not use systemic antibiotics routinely for ingrown nails without proven infection 5

Antibiotic Selection

• Target Staphylococcus aureus and gram-positive organisms as the primary pathogens 1
• Recommended oral antibiotics include:
  • First-generation cephalosporins
  • Amoxicillin-clavulanate
  • Clindamycin
  • Doxycycline 1

Surgical Management for Moderate to Severe Cases

When to Proceed to Surgery

• Surgical approaches are indicated when conservative measures fail, for moderate to severe ingrown nails, or when there is recurrent disease 2, 3
• Reassess after 2 weeks of conservative treatment; if no improvement or worsening, proceed to surgical intervention 1

Partial Nail Avulsion with Phenolization

• Partial nail avulsion combined with phenolization is the most effective treatment for preventing symptomatic recurrence compared to surgical excision alone 3
• This approach removes the lateral edge of the nail plate and chemically destroys the nail matrix to prevent regrowth 3
• Note the trade-off: phenolization has a slightly increased risk of postoperative infection compared to surgical excision without phenolization, but superior recurrence prevention 3

Alternative Surgical Options

• Complete nail excision with or without phenolization 3
• Electrocautery, radiofrequency, or carbon dioxide laser ablation of the nail matrix 3
• If subungual hematoma or abscess develops, partial or total nail avulsion may be required in addition to antibiotics 1

Important Clinical Pitfalls

Avoid These Common Errors

• Do not start treatment on clinical grounds alone if fungal infection (onychomycosis) is suspected; laboratory confirmation with microscopy and culture is essential before initiating antifungal therapy 6
• Prophylactic antibiotics are not indicated for clean puncture wounds or ingrown nails without signs of infection 1
• Oral antibiotics before or after phenolization do not improve outcomes in surgical management 3

Differential Diagnosis Considerations

• Distinguish ingrown nail from paronychia: paronychia involves inflammation of the proximal and/or lateral nail folds and may be acute (bacterial/viral) or chronic (contact dermatitis, secondary colonization) 5
• Consider onychomycosis if there is nail thickening, discoloration, or onycholysis; this requires laboratory confirmation before treatment 6
• Paronychia from chemotherapy or targeted therapy (EGFR inhibitors) requires different management with topical povidone iodine 2%, topical beta-blockers, or topical antibiotics/corticosteroids 6

Follow-Up and Prevention

Monitoring

• Regular monitoring for complications including chronic infection or abscess formation is crucial 1
• Reassess at 2 weeks to determine treatment response 1

Patient Education for Prevention

• Teach proper nail trimming technique: cut nails straight across, not too short 7, 2
• Wear comfortable, well-fitting shoes and cotton socks 6, 2
• Avoid repeated trauma or excessive pressure on the toes 6, 2
• Manage hyperhidrosis and maintain good foot hygiene 2, 3