Treatment of Infected Ingrown Toenail in a Healthy Adolescent
For this infected ingrown toenail with local signs only (redness, cloudy discharge, pain) in a healthy 17-year-old, initiate warm salt water soaks 2-3 times daily combined with topical antibiotic ointment (polysporin), and reserve oral antibiotics only if symptoms worsen or fail to improve within 48-72 hours. 1, 2
Initial Management Approach
Start with conservative local wound care:
- Apply warm salt water soaks for 15-20 minutes, 2-3 times daily to reduce inflammation and promote drainage 1, 3
- After each soak, apply a small amount of polysporin (antibiotic ointment) to the affected area 1-3 times daily, covering with a sterile bandage 4
- Elevate the foot when possible to reduce swelling 5
When to Add Oral Antibiotics
Oral antibiotics are NOT immediately necessary for localized infection without systemic signs. 2 A prospective randomized study of 54 patients with infected ingrown toenails found no significant difference in healing time between those receiving antibiotics plus local treatment versus local treatment alone (1.9 weeks vs 2.0 weeks). 2
Add oral antibiotics only if:
- No improvement after 48-72 hours of conservative care 1
- Cellulitis extends beyond the immediate nail fold area 5
- Purulent drainage increases 5
- Systemic symptoms develop (fever, chills, malaise) 5
Antibiotic Selection (If Needed)
If oral antibiotics become necessary, the preferred agent from your available options is doxycycline 100mg twice daily for 7-10 days. 5 This covers the most common pathogens in skin and soft tissue infections, including Staphylococcus aureus and Streptococcus species. 5
Alternative options in order of preference:
- Amoxicillin (if available) - provides coverage for streptococci and some staphylococci, though less ideal for potential MRSA 5
- Azithromycin - less optimal due to narrower spectrum and increasing resistance patterns 5
Avoid azithromycin as first-line unless the patient has a documented allergy to other agents, as it has inferior coverage for typical skin pathogens compared to doxycycline. 5
Duration of Treatment
Continue conservative care until complete resolution of infection signs:
- For mild infections with local treatment only: typically 1-2 weeks 5, 1
- If oral antibiotics are added: 7-10 days is usually sufficient 5, 1
- Treatment should continue until infection resolves, not necessarily until the wound fully heals 5
Critical Monitoring Parameters
Reassess within 48-72 hours to evaluate response:
- Decreasing erythema and pain indicate appropriate response 1
- Increasing redness, warmth, swelling, or purulent drainage requires escalation to oral antibiotics 5, 1
- Development of red streaking, lymphangitis, or systemic symptoms requires urgent medical evaluation 5
Common Pitfalls to Avoid
Do not routinely prescribe antibiotics for all infected ingrown toenails. 1, 2 Evidence shows that local wound care alone is equally effective for localized infections without cellulitis. 2
Do not continue antibiotics beyond necessary duration (typically 1-2 weeks maximum for mild infections). 1 Prolonged courses increase resistance risk without improving outcomes. 5
Do not neglect adequate wound care despite antibiotic therapy. 1 Local measures (soaking, drainage, topical antibiotics) are as important as systemic treatment. 5
Prevention of Recurrence
Once infection resolves, provide preventive instructions:
- Cut toenails straight across, not rounded at corners 1
- Avoid cutting nails too short 1
- Wear properly fitting shoes and cotton socks 1
- Keep feet clean and dry 1
When to Seek Advanced Care
Refer for surgical evaluation if: