Ingrown Toenail Treatment
Start with conservative management for early-stage ingrown toenails, but proceed directly to partial nail avulsion with phenolization for moderate-to-severe cases or when conservative treatment fails, as this is the most effective approach for preventing recurrence. 1, 2
Initial Conservative Management (Stage I Only)
For early-stage ingrown toenails without significant infection or severe inflammation, attempt conservative measures first: 1, 3
- Soak the affected toe in warm, soapy water or dilute antiseptic solution for 10-15 minutes twice daily to reduce inflammation and prevent infection 1
- Correct footwear immediately by switching to comfortable, well-fitting shoes with adequate toe box space to eliminate pressure on the toenail 1
- Trim toenails straight across—never too short and never rounded at the corners—to prevent worsening 1
- If fungal infection is suspected as a contributing factor, obtain cultures and initiate appropriate antifungal therapy 1
Conservative treatment should be abandoned quickly if there is no rapid improvement, as prolonged conservative management in moderate-to-severe cases delays definitive treatment and increases complication risk. 3
Surgical Management (Stage II-III or Failed Conservative Treatment)
The definitive treatment is partial nail avulsion of the ingrown edge combined with chemical matricectomy using phenol, as this combination is more effective at preventing symptomatic recurrence compared to surgical excision alone, despite a slightly increased risk of postoperative infection. 2, 4, 3
Surgical Approach:
- Perform partial nail extraction removing only the ingrown nail edge (not complete nail removal) 3
- Follow immediately with destruction of the corresponding portion of the nail matrix using phenolization 4, 3
- Do NOT perform complete nail avulsion as routine treatment—evidence shows disappointing results and it is not recommended 2
Alternative Surgical Techniques:
If phenolization is not available or contraindicated, other matrix destruction methods include: 5, 4
Partial nail avulsion with phenolization and direct surgical excision of the nail matrix are equally effective, so either can be chosen based on available resources and surgeon expertise. 4
Post-Procedure Care
After surgical intervention, implement the following regimen: 1
- Continue antiseptic soaks with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily 1
- Apply mid-to-high potency topical steroid ointment to nail folds twice daily to reduce inflammation 1
- Avoid trauma to the affected digit and wear protective footwear 1
- Oral antibiotics before or after phenolization do NOT improve outcomes and should not be used routinely 4
Special Considerations for Diabetic Patients
Diabetic patients require immediate treatment by an appropriately trained healthcare professional due to high risk of foot ulceration and complications: 1, 2
- Assess for signs of infection and poor circulation before any procedure 2
- For diabetic patients with non-rigid hammertoes and nail changes, consider digital flexor tendon tenotomy rather than nail removal as first-line surgical intervention 1, 2
- Never delay treatment in diabetic patients, as ingrown toenails can rapidly progress to foot ulcers 1, 2
Prevention of Recurrence
After successful treatment, prevent recurrence through: 1
- Patient education on proper nail trimming technique (straight across, not rounded) 1
- Wearing appropriate footwear that accommodates foot shape without pressure 1
- Daily application of topical emollients to cuticles and periungual tissues to maintain skin barrier function 1
Common Pitfalls to Avoid
- Do not perform complete nail avulsion for routine ingrown toenail treatment—it has disappointing outcomes and higher recurrence rates 2
- Do not continue conservative treatment beyond early-stage disease or when rapid improvement is not seen 3
- Do not perform nail procedures in diabetic patients without first assessing vascular status and infection risk 2
- Ensure all procedures are performed by appropriately trained healthcare professionals to avoid complications 2