What is the best management approach for an elderly male with an ingrown toenail, uncontrolled Diabetes Mellitus (DM) with a last Hemoglobin A1c (HbA1c) of 9.0, Chronic Kidney Disease (CKD) with Impaired Renal Function, and mobility issues?

Management of Ingrown Toenail in High-Risk Diabetic Patient

This patient requires urgent referral to a multidisciplinary diabetic foot team for evaluation and likely surgical management, as conservative measures alone are insufficient given his multiple high-risk features including uncontrolled diabetes (HbA1c 9.0), advanced CKD (GFR 32), and mobility impairment. 1

Immediate Risk Assessment

This patient has multiple factors placing him at extremely high risk for complications:

• Uncontrolled diabetes (HbA1c 9.0) significantly increases infection risk and impairs wound healing 1
• Advanced CKD (GFR 32) further compromises immune function and healing capacity 1
• Mobility impairment (using cane) suggests possible peripheral neuropathy and/or peripheral arterial disease, both critical risk factors for poor outcomes 1
• Ingrown toenails are significant predictors for diabetic foot ulcer development, which can lead to amputation 1

Urgent Evaluation Required

Before any treatment, this patient needs immediate assessment for:

• Presence of infection - look for erythema extending beyond the nail fold, purulent drainage, warmth, systemic signs (fever, elevated WBC), or any fluctuance suggesting abscess 1
• Peripheral arterial disease - check pedal pulses, ankle-brachial index (ABI), capillary refill, and skin temperature 1
• Peripheral neuropathy - assess protective sensation with monofilament testing 1
• Depth of tissue involvement - determine if there is exposed bone or deep tissue infection 1

Management Algorithm

If NO Signs of Infection Present:

Refer to podiatry/foot surgery within 1-2 weeks for definitive surgical management rather than attempting conservative measures 1

• Surgical partial nail avulsion with phenol matricectomy is the treatment of choice for this high-risk patient, as it has superior outcomes in preventing recurrence compared to conservative management 2, 3
• Conservative measures (cotton wisps, soaking, gutter splints) have high failure rates and are inappropriate as primary treatment in diabetic patients with multiple comorbidities 2, 3

If Signs of Infection ARE Present:

This constitutes a diabetic foot infection requiring urgent (same-day) multidisciplinary evaluation 1, 4

• Obtain wound cultures from deep tissue (not superficial swab) before starting antibiotics 1
• Initiate empiric antibiotics immediately:
  • For mild infection: oral agents covering Staphylococcus aureus (including MRSA if risk factors present) - options include trimethoprim-sulfamethoxazole, doxycycline, or clindamycin 1
  • For moderate-to-severe infection: parenteral therapy with piperacillin-tazobactam or vancomycin plus ceftazidime 1, 4
• Urgent surgical consultation if there is fluctuance, deep abscess, extensive cellulitis, or any necrotic tissue 1, 4

Concurrent Essential Management

Optimize glycemic control aggressively - target HbA1c <7% to reduce microvascular complications and improve wound healing 1

Implement strict foot care protocols immediately: 1

• Daily foot inspection by patient or caregiver
• Appropriate therapeutic footwear (never barefoot or thin-soled slippers) 5
• Skin cleansing and topical moisturizing creams
• Immediate reporting of any new lesions

Assess and manage cardiovascular risk factors: 1

• Blood pressure control (target <130/80 mmHg in diabetics)
• Statin therapy to achieve LDL-C <55 mg/dL given very high cardiovascular risk
• Antiplatelet therapy if peripheral arterial disease confirmed

Consider SGLT2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) if GFR permits (≥30 mL/min/1.73 m²), as these reduce renal endpoints and cardiovascular events 1

Critical Pitfalls to Avoid

• Do NOT attempt conservative management as primary treatment in this high-risk diabetic patient - the risk of progression to serious infection or ulceration is too high 1
• Do NOT delay referral - even seemingly minor foot problems in diabetics with neuropathy and/or PAD can rapidly progress to limb-threatening infections 1
• Do NOT prescribe antibiotics without obtaining cultures first if infection is present 1
• Do NOT overlook assessment for peripheral arterial disease - the combination of infection and ischemia dramatically worsens outcomes and may require vascular surgery consultation 1
• Do NOT allow patient to continue walking on affected foot without proper offloading - this will worsen tissue damage 1, 5