What is the recommended treatment for an ingrown toenail?

Treatment for Ingrown Toenail

Start with conservative management using twice-daily antiseptic soaks combined with topical corticosteroids for mild ingrown toenails, and escalate to surgical partial nail avulsion with phenolization for moderate-to-severe or recurrent cases. 1

Initial Conservative Treatment (First-Line for Mild Cases)

For mild ingrown toenails without significant infection, begin with a structured conservative approach:

• Perform antiseptic soaks twice daily for 10-15 minutes using either dilute vinegar (50:50 dilution) or 2% povidone-iodine solution 1
• Apply mid- to high-potency topical corticosteroid ointment to the affected nail fold twice daily immediately after soaking to reduce local inflammation 1
• Consider mechanical separation techniques such as cotton wisp or dental floss insertion under the ingrown lateral nail edge, or gutter splinting using a plastic tube placed on the lateral nail edge 1, 2
• Taping the lateral nail fold away from the nail plate can provide immediate pain relief 1, 2

Antibiotic Therapy (Only When Indicated)

Do not routinely prescribe antibiotics unless clear signs of infection are present:

• Reserve antibiotics for cases with purulent drainage requiring culture or localized cellulitis with significant erythema extending beyond the nail fold 1
• Target Staphylococcus aureus and gram-positive organisms when antibiotics are needed 1
• For recurrent, severe, or treatment-refractory cases, use doxycycline 100 mg twice daily with follow-up after one month 1

When to Escalate to Surgical Management

Reassess after 2 weeks of conservative management and escalate to surgical consultation if:

• Persistent pain or drainage continues beyond 2-4 weeks despite appropriate conservative therapy 1
• Granulation tissue develops 1
• Moderate to severe cases that fail initial conservative measures 2

Surgical approaches are superior to nonsurgical ones for preventing recurrence 2:

• Partial nail avulsion of the lateral edge combined with phenolization is the most effective approach, preventing symptomatic recurrence better than surgical excision alone 3, 2
• Note that phenolization carries a slightly increased risk of postoperative infection compared to surgical excision without phenolization, but the recurrence prevention benefit outweighs this risk 3
• Complete nail excision with or without phenolization is reserved for severe recurrent cases 3

Prevention of Recurrence

Patient education is critical to prevent recurrence:

• Trim toenails straight across, not too short 1, 2
• Wear comfortable and well-fitting shoes to avoid external pressure 1
• Apply topical emollients daily to cuticles and periungual tissues 1
• Avoid manipulating cuticles or using nails as tools 1
• Wear protective gloves when working with water or chemicals 1
• Manage hyperhidrosis and onychomycosis if present 2

Special Population: Diabetic Patients

For diabetic patients, use more aggressive monitoring and prompt treatment:

• Ingrown toenails can progress to foot ulceration with significant morbidity in diabetics 1
• Provide integrated foot care every 1-3 months 1
• Ensure treatment by trained healthcare professionals rather than self-management 1

Common Pitfalls to Avoid

• Do not use oral antibiotics before or after phenolization routinely, as they do not improve outcomes 3
• Avoid terbinafine if fungal infection is suspected, as it has limited activity against Candida; use topical imidazole lotions or oral itraconazole instead 4
• Do not delay surgical referral beyond 2-4 weeks if conservative management fails, as this increases risk of complications 1