What are the treatment options for ingrown toenail relief?

Treatment of Ingrown Toenail

For mild to moderate ingrown toenails, start with conservative management including twice-daily antiseptic soaks with dilute vinegar (50:50) or 2% povidone-iodine for 10-15 minutes, followed immediately by application of mid- to high-potency topical corticosteroid ointment to the nail fold twice daily. 1, 2, 3

Initial Conservative Management

Antiseptic Soaking Protocol

• Perform warm antiseptic soaks twice daily for 10-15 minutes using either dilute vinegar (50:50 dilution with water) or 2% povidone-iodine solution 1, 2, 3
• This reduces inflammation and prevents secondary infection 2

Topical Anti-inflammatory Treatment

• Apply mid- to high-potency topical corticosteroid ointment to the affected nail fold twice daily, immediately after completing the antiseptic soak 1, 2, 3
• The ointment vehicle is preferred over cream for better penetration and occlusion in the periungual area 2

Mechanical Relief Techniques

• Consider gutter splinting by placing a plastic tube with a lengthwise incision on the lateral edge of the nail to encapsulate it and provide immediate pain relief 1, 2, 3
• Alternatively, insert cotton wisps or dental floss under the ingrown lateral nail edge to separate it from the underlying tissue 2, 3, 4
• Taping the lateral nail fold away from the nail plate is another option 3

When to Add Antibiotics

Do not routinely prescribe antibiotics for mild ingrown toenails unless clear signs of infection are present. 3

Indications for Antibiotic Therapy

• Start oral antibiotics only if pus is present, purulent drainage occurs, or localized cellulitis with significant erythema extends beyond the nail fold 2, 3
• Obtain cultures if pus is present before initiating antibiotics 2
• Use cephalexin as first-line therapy targeting Staphylococcus aureus and gram-positive organisms 1, 3
• If initial treatment fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 1
• Be aware that secondary bacterial or mycological superinfections occur in up to 25% of cases 1

Treatment-Refractory Cases

• For recurrent, severe, or treatment-refractory cases after 2-4 weeks, consider doxycycline 100 mg twice daily with follow-up after one month 2, 3

Management of Granulation Tissue

If granulation tissue (pyogenic granuloma) develops despite topical corticosteroids:

• Consider scoop shave removal with hyfrecation or silver nitrate chemical cauterization 1, 2
• Add topical timolol 0.5% gel twice daily under occlusion as adjunctive therapy 1, 2
• For treatment-refractory cases, consider intralesional triamcinolone acetonide 1, 2

When to Consider Surgical Intervention

Consider partial nail avulsion if pain is intolerable despite conservative management, or if persistent pain or drainage continues beyond 2-4 weeks. 1, 3

• Partial nail avulsion may also be considered if a painful hematoma or subungual abscess is present 1
• Surgical approaches are superior to nonsurgical ones for preventing recurrence 4
• Partial nail avulsion combined with phenolization is more effective at preventing symptomatic recurrence than surgical excision alone, though it carries a slightly increased risk of postoperative infection 5

Prevention of Recurrence

Nail Care Education

• Cut toenails straight across, not too short—never round the corners 1, 2, 3
• Avoid cutting cuticles or manipulating the nail folds 2

Footwear and Hygiene

• Wear comfortable, well-fitting shoes and cotton socks to avoid repeated trauma 1, 2, 3
• Maintain good hand and foot hygiene 2
• Wear protective gloves when working with water or chemicals 1, 2, 3

Skin Barrier Maintenance

• Apply topical emollients daily to cuticles and periungual tissues to maintain skin barrier function 1, 2, 3
• Avoid artificial nails and harsh nail products 2

Follow-up and Monitoring

• Reassess after 2 weeks of conservative treatment 1, 3
• If no improvement is seen after 2-4 weeks, escalate to surgical consultation 3
• Monitor for signs of infection including increased pain, redness, swelling, or purulent drainage 2

Special Considerations for Diabetic Patients

• Provide more aggressive monitoring and prompt treatment by trained healthcare professionals, as ingrown toenails can progress to foot ulceration with significant morbidity in diabetic patients 3
• Integrated foot care should be provided every 1-3 months for diabetic patients 3

Important Clinical Caveats

• Stop topical steroids immediately if infection develops; obtain cultures and initiate appropriate antibiotics before resuming steroid therapy 2
• Do not use footbaths where feet are soaked for prolonged periods, as they induce skin maceration 6
• Conservative treatment is typically used for mild to moderate cases, whereas surgical approaches are reserved for moderate and severe cases 4