What is the treatment for an ingrown toenail?

Treatment of Ingrown Toenail

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

Initial Conservative Management

The foundation of treatment involves a structured approach combining antiseptic care with anti-inflammatory therapy:

• Perform antiseptic soaks twice daily for 10-15 minutes using either dilute vinegar (50:50 dilution with water) or 2% povidone-iodine solution 1, 2
• Apply mid- to high-potency topical corticosteroid ointment to the affected nail fold twice daily, immediately after completing the soak (ointment vehicle is preferred over cream for better penetration) 1, 2
• Consider mechanical separation techniques such as placing cotton wisps or dental floss under the ingrown lateral nail edge to separate it from underlying tissue 1, 3
• Gutter splinting can be performed using a plastic tube with a lengthwise incision placed on the lateral nail edge to encapsulate it and provide immediate pain relief 1, 3

When to Add Antibiotics

Do not routinely prescribe antibiotics for mild ingrown toenails unless clear signs of infection are present. 2

Antibiotic indications include:

• Purulent drainage requiring culture 2
• Localized cellulitis with significant erythema extending beyond the nail fold 2
• Coverage should target Staphylococcus aureus and other gram-positive organisms 1, 2
• For recurrent, severe, or treatment-refractory cases after 2-4 weeks, use doxycycline 100 mg twice daily with follow-up after one month 1, 2

Management of Granulation Tissue

If granulation tissue develops despite initial conservative therapy:

• Continue high-potency topical corticosteroids and consider adding topical timolol 0.5% gel twice daily under occlusion as adjunctive therapy 1
• Procedural options include scoop shave removal with hyfrecation or silver nitrate chemical cauterization 1
• For treatment-refractory cases, consider intralesional triamcinolone acetonide 1

Reassessment and Escalation Criteria

Reassess after 2 weeks of conservative management. 2

Escalate to surgical consultation if:

• Persistent pain or drainage continues beyond 2-4 weeks despite appropriate conservative therapy 1, 2
• Granulation tissue develops and fails to respond to topical treatments 2
• Recurrent episodes occur despite proper preventive measures 2

Surgical Intervention

Partial nail avulsion combined with phenolization is more effective than surgical excision alone at preventing symptomatic recurrence, though it carries a slightly increased risk of postoperative infection. 4

For patients requiring surgery:

• Partial avulsion of the lateral edge of the nail plate is the most common surgical approach 3, 4
• Matrixectomy (chemical, surgical, or electrosurgical) further prevents recurrence 3, 4
• Continue antiseptic soaks if inflammation persists post-procedure 1
• Monitor wound healing at 2 weeks post-procedure for signs of infection including increased pain, redness, swelling, or purulent drainage 1

Prevention of Recurrence

Patient education is critical to prevent recurrence:

• Trim toenails straight across, never rounded at the corners, and avoid cutting them too short 2, 5
• Wear comfortable, well-fitting shoes with adequate toe room and cotton socks to prevent pressure and friction 2, 5
• Apply topical emollients daily to cuticles and periungual tissues to maintain skin barrier function 1, 2
• Avoid manipulating cuticles or using nails as tools 2
• Wear protective gloves when working with water or chemicals 1, 2

Special Populations: Diabetic Patients

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. 6, 2

• Integrated foot care should be provided every 1-3 months 2
• Ingrown or thickened toenails require immediate treatment by an appropriately trained healthcare professional 6
• Consider digital flexor tendon tenotomy for non-rigid hammertoes with nail changes, excess callus, or pre-ulcerative lesions that fail to respond to non-surgical treatment 6

Common Pitfalls to Avoid

• Do not stop topical steroids abruptly if infection develops—obtain cultures, initiate appropriate antibiotics, then resume steroid therapy once infection is controlled 1
• Avoid artificial nails and harsh nail products during treatment and recovery 1
• Do not perform surgical procedures in patients with poor arterial supply without careful consideration of non-healing risk 6