Treatment of Ingrown Toenail Infection
For an infected ingrown toenail, treatment should be stratified by severity: mild infections (Grade 1) require topical antiseptics like povidone-iodine 2%, moderate infections (Grade 2) need cultures plus topical therapy with consideration of oral antibiotics if spreading cellulitis is present, and severe infections (Grade 3) require oral antibiotics, cultures, and partial nail avulsion to remove the infectious source. 1
Severity-Based Treatment Algorithm
Grade 1 (Mild Infection)
- Apply topical povidone-iodine 2% or topical antibiotics with corticosteroids to the affected nail fold 1
- Reassess after 2 weeks; if worsening, escalate to Grade 2 treatment 1
- Conservative measures include warm water soaks with Epsom salt, which can be combined with antiseptic solutions 2
Grade 2 (Moderate Infection)
- Obtain bacterial, viral, and fungal cultures before initiating treatment 1
- Continue topical povidone-iodine 2% or topical antibiotics with corticosteroids 1
- Add oral antibiotics if signs of spreading infection or cellulitis are present 1
- Reassess after 2 weeks; if no improvement, progress to Grade 3 management 1
Grade 3 (Severe Infection)
- Interrupt normal activities until clinical improvement occurs 1
- Obtain bacterial, viral, and fungal cultures 1
- Implement both topical treatments and oral antibiotics concurrently 1
- Strongly consider partial nail avulsion to remove the source of infection, as this addresses the underlying mechanical trauma driving the infectious process 1, 3
- Reassess after 2 weeks 1
Surgical Considerations for Infected Cases
Partial nail avulsion combined with phenolization is more effective than surgical excision alone at preventing recurrence, though it carries a slightly increased risk of postoperative infection 3. This approach is superior to nonsurgical treatment for preventing recurrence 4.
- Oral antibiotics given before or after phenolization do not improve outcomes, so their use should be reserved for active infection rather than prophylaxis 3
- Chemical matricectomy with phenol is the most effective, safe, and commonly performed surgical method for definitive treatment 5
Prevention of Recurrence
Once the infection is controlled, preventing recurrence requires addressing predisposing factors:
- Educate on proper nail trimming technique (cutting straight across rather than curved) 6, 1
- Apply daily topical emollients to cuticles and periungual tissues 1
- Recommend properly fitting footwear with adequate toe box space 1, 4
- Treat underlying hyperhidrosis and onychomycosis if present, as these contribute to recurrence 1, 4
- Use absorbent socks and antifungal powders in shoes to reduce moisture 1
Common Pitfalls
The evidence shows that Grade 1 infections often resolve with conservative management alone, but clinicians frequently delay appropriate escalation when patients fail to improve at 2 weeks. Additionally, attempting surgical intervention without adequate infection control in Grade 3 cases increases complication risk. Always obtain cultures in Grade 2 and 3 infections to guide antibiotic selection, particularly given the potential for atypical organisms in chronic cases.