Treatment of Ingrown Toenails
Start with conservative medical management using twice-daily antiseptic soaks combined with topical corticosteroids, and reserve surgical intervention for cases that fail to improve after 2-4 weeks or present with severe infection. 1, 2, 3
Initial Conservative Management for Mild Cases
Antiseptic Soaking Protocol
- Perform antiseptic soaks twice daily for 10-15 minutes using either dilute vinegar (50:50 dilution with water) or 2% povidone-iodine solution 1, 3
- Povidone-iodine 2% is the most evidence-based first-line antiseptic agent according to the American Academy of Dermatology 2
Anti-Inflammatory Treatment
- Immediately after each soak, apply a mid- to high-potency topical corticosteroid ointment to the affected nail fold twice daily to reduce local inflammation 1, 3
- Do not use topical steroids if purulent drainage is present 2
Mechanical Relief Techniques
- Insert cotton wisps or dental floss under the ingrown lateral nail edge to separate it from the underlying inflamed tissue 1, 3, 4
- Alternatively, place a plastic tube with a lengthwise incision (gutter splint) on the lateral nail edge to encapsulate it 1, 5
- Tape the lateral nail fold away from the nail plate to reduce pressure 2, 3
Management of Infected Ingrown Toenails
When to Add Antibiotics
- Do not routinely prescribe antibiotics for mild ingrown toenails unless clear signs of infection are present, such as purulent drainage or localized cellulitis with significant erythema extending beyond the nail fold 3
- If pus is present, obtain cultures before initiating antibiotics 1
- For mild-to-moderate infections, prescribe cephalexin or amoxicillin-clavulanate for 1-2 weeks targeting Staphylococcus aureus and gram-positive organisms 2, 3
- Up to 25% of cases have bacterial or fungal superinfections involving both gram-positive and gram-negative organisms 2
Treatment-Refractory Cases
- For recurrent, severe, or treatment-refractory cases after 2-4 weeks, consider oral doxycycline 100 mg twice daily with follow-up after one month 1, 3
Management of Granulation Tissue
- If granulation tissue persists despite topical corticosteroids, consider scoop shave removal with hyfrecation or silver nitrate chemical cauterization 1
- Add topical timolol 0.5% gel twice daily under occlusion as adjunctive therapy for persistent granulation tissue 1
- For treatment-refractory cases, consider intralesional triamcinolone acetonide 1
When to Escalate to Surgical Intervention
Timing Criteria
- Reassess after 2 weeks of conservative management; if persistent pain or drainage continues beyond 2-4 weeks despite appropriate therapy, escalate to surgical consultation 1, 3
- Do not delay surgical intervention beyond 2 weeks if medical management fails 2
Immediate Surgical Indications
- Severe infections with deep abscess, extensive tissue involvement, or substantial necrosis require immediate surgical consultation 2
- Recurrent cases that have failed multiple conservative attempts warrant surgical management 2, 6
Surgical Options
- Partial nail avulsion followed by either phenolization or direct surgical excision of the nail matrix are equally effective 4, 5
- Partial nail avulsion combined with phenolization is more effective at preventing symptomatic recurrence compared to surgical excision without phenolization, though it carries a slightly increased risk of postoperative infection 4
Prevention of Recurrence
Patient Education Essentials
- Trim toenails straight across and not too short 1, 3
- Wear comfortable, well-fitting shoes and cotton socks to avoid repeated trauma 1, 3
- Apply topical emollients daily to cuticles and periungual tissues to maintain skin barrier function 1, 3
- Avoid cutting cuticles or manipulating the nail folds 1, 3
- Wear protective gloves when working with water or chemicals 1, 3
- Avoid artificial nails and harsh nail products 1
- Maintain good hand hygiene 1
Post-Treatment Monitoring
- Continue antiseptic soaks if inflammation persists after any intervention 1
- Reassess wound healing at 2 weeks post-procedure to determine if additional interventions are needed 1
- Monitor for signs of infection including increased pain, redness, swelling, or purulent drainage 1