Treatment of Ingrown Toenail in the Emergency Room
For ingrown toenail removal in the ER, initiate immediate conservative management with warm antiseptic soaks using 2% povidone-iodine twice daily, apply mid-to-high potency topical corticosteroid ointment to reduce inflammation, and perform cotton packing or gutter splinting to separate the nail edge from the lateral fold; if purulent infection is present, add oral antibiotics (cephalexin or amoxicillin-clavulanate) for 1-2 weeks, and escalate to partial nail avulsion with phenolization if there is no improvement after 2 weeks of medical management. 1, 2, 3
Immediate Assessment and Initial Management
First-Line Conservative Treatment
- Apply 2% povidone-iodine solution twice daily as the most evidence-based antiseptic agent for infected ingrown toenails 1, 2
- Instruct the patient to perform warm antiseptic soaks for 10-15 minutes twice daily using either povidone-iodine or dilute vinegar (50:50 dilution) to reduce bacterial load and inflammation 1, 2
- Apply mid-to-high potency topical corticosteroid ointment to the nail folds twice daily to reduce inflammation and edema, but avoid if purulent drainage is present 1, 2, 3
Mechanical Relief Measures
- Perform cotton packing or dental floss insertion under the ingrown lateral nail edge to separate it from the underlying tissue and provide immediate pain relief 1, 3, 4
- Apply gutter splinting to the ingrown nail edge as an alternative mechanical relief method 3, 4
- Tape the lateral nail fold away from the nail plate to reduce pressure 2
Antibiotic Therapy for Infected Cases
When to Prescribe Antibiotics
- Obtain bacterial cultures if there is significant purulence or signs of spreading infection 1
- Up to 25% of ingrown toenails have bacterial or fungal superinfections involving both gram-positive and gram-negative organisms 2
Antibiotic Selection and Duration
- Prescribe cephalexin or amoxicillin-clavulanate for 1-2 weeks for mild-to-moderate infections 2
- Continue antibiotics for 1-2 weeks for mild infections, with some requiring an additional 1-2 weeks 2
- For moderate-to-severe infections, 2-4 weeks is usually sufficient, depending on the adequacy of debridement and wound vascularity 2
Surgical Intervention Criteria
When to Escalate to Surgery
- Reassess after 2 weeks of medical management; if no improvement, escalate to surgical intervention 2
- Severe infections with deep abscess, extensive tissue involvement, or substantial necrosis require immediate surgical consultation 2
- Recurrent or treatment-refractory cases warrant surgical management 2
Surgical Technique
- Partial nail avulsion of the lateral edge is the most common surgical approach and is superior to nonsurgical methods for preventing recurrence 3, 4
- Combine partial nail avulsion with phenolization (chemical matricectomy) as this is more effective at preventing symptomatic recurrence compared to surgical excision alone, though it carries a slightly increased risk of postoperative infection 4
- Partial nail avulsion followed by either phenolization or direct surgical excision of the nail matrix are equally effective 4
Special Populations
High-Risk Patients
- For patients with diabetes or immunocompromised status, have a lower threshold for oral antibiotics and surgical intervention 1
- Carefully examine interdigital toe spaces for fissuring, scaling, or maceration, as treating these conditions may reduce recurrent infection 1
Critical Pitfalls to Avoid
- Do not delay surgical intervention beyond 2 weeks if medical management fails 2
- Do not use topical steroids in the presence of purulent drainage 2
- Do not prescribe clindamycin as first-line therapy 2
- Avoid manipulation of the cuticles and trauma to the affected area 1